minimally invasive management of BPH

1. Minimally Invasive &
Endoscopic Management of BPH
SPECIFIC TECHNOLOGIES

2.  NONLASER OPTIONS
 Bipolar TURP
 TUVP
 TUMT
 TUNA
 TUIP
 LASER TREATMENTS
 Holmium prostate
enucleation
 Laser prostate ablation &
vaporization
 Thullium laser
 MINIMALLY INVASIVE
 Prostate Stents
 Prostate Urethral Lift
 Prostate Embolization
 Prostatic Injections

3.  Bipolar resection uses a specialized resecting loop
that incorporates both the active and the return
portions of the circuit on the same electrode.
 Gyrus Plasma Kinetic (PK) Tissue Management
System is the commonly used B-TURP technology
wherein energy is initially transmitted from the loop
into the surrounding saline.
BIPOLAR-TURP

4. BIPOLAR LOOP
Made of Platinum Iridium
instead of the standard Tungsten

5. Allows tissue
resection at lower
temperatures with
a lower voltage.
More simultaneous
cutting of tissue
with sealing of
vessels
Overall improved
hemostasis
BIPOLAR-TURP

6. Lower voltage
and temperature
used in the
plasma system
Minimize tissue
charring
Decrease in
unnecessary
tissue
coagulation
Decrease in
storage
symptoms
BIPOLAR-TURP

7. BIPOLAR-TURP
 TECHNIQUE:
 Almost identical
 Quicker resections
 Initial drag on the loop

8.  Outcomes:
 Comparative studies….M-& B-TURP
 Changes in AUASS & Qmax…No statistical diff.
 Diff in blood loss
 Time with catheter
 Post-op complications.. hematuria, clot retention &
blood transfusion
 favour B-TURP.

9.  COMPLICATIONS
 15.5%...B-TURP vs. 28.6%...M-TURP ( p < 0.001)
Issa Medline review 1997-2007

10.  Improved hemostasis
 Absent risk of TUR syndrome
 Longer resection times can be allowed
 Ability to treat larger glands.
 Improved visualization
 Decrease in capsular perforations
 Decrease in overall immediate reoperation rate

11. CONCLUSION:
 Encouraging results
 Will likely replace M-TURP as the gold standard for
BPH treatment.

12. TUVP
 Transurethral Vaporization of the Prostate

13. Fluted electrode

14. `
Vaportrode electrode Spiked electrode

15. Plasma Button electrode

17. TUVP-Results
 Comparable to TURP with regard to improvements
in voiding symptoms.
 Durability ?
 concern about
 dysuria and
 re-treatment rates

18. TUMT
 Trans Urethral Microwave Therapy
 Objective:
 Locally thermo ablate the prostate tissue while
maintaining normal temperatures in the surrounding
non-targeted tissue ( Sphincter, bladder neck &
rectum )
 EM waves of frequency 915-1296 MHz.
 Temp > 650C.

19. Cooled Thermo Therapy TUMT catheter

20. TUMT

22.  Advantages:
 In-office procedure
 Rapid Pt. convalescence
 Minimal anesthesia
 Least operator dependent
 Easy learning curve

23.  Before TUMT, Cystoscopy required
 Exclude presence of median lobe
 Prostatic length > 25mm
 Prostate size---30-100g

24.  Contraindications:
 Implanted pace-makers
 Defibrillators
 Inflatable penile prosthesis
 AUS
 Pelvic metal implants—THR
 Urethral strictures
 Previous invasive BPH treatment
 PAD with claudication
 Prostate cancer
 Bladder cancer
 Underlying neurologic disorders

25.  Outcomes:
 Reduced overall LUTS improvement
 Lack of durability
 60% reduction in symptom scores @ 3m of follow-up
 @3y …only 45% improvement
 Re-treatment…..20% of patients.

26. TURP
 Improvement in all
outcomes
 Incidence of adverse events
higher
TUMT
 Only AUASS improved
 Multiple other factors
worsened
 Prolonged postoperative

27. TUMT-COMPLICATIONS
 Intraop & Periop
 Sensation of local, perineal
warmth
 Urge to urinate
 Penile necrosis
 Urethral fistulae
 Postop
 Urethral stricture &
bladder neck stenosis-2%
 Transient incontinence-2%
 Prolonged catheterization
times
 AUR
 UTI

28.  CONCLUSION
 TUMT…continuum of BPH treatment
 Reasonable replacement for medical therapy

29. TUNA
 Composed of
 a radiofrequency (RF) generator,
 a disposable urethral endoscopic catheter that
attaches to a reusable catheter handle, and
 an optics system

30. TUNA handpiece

31. DeployedTUNA needles

33. The treated prostate in TUNA
Spheroid area of coagulative necrosis

34. TUNA1st performed in
1993
FDA approved in
1996
Updated in
2003

35.  Indicated in men with
 bothersome LUTS
 who are refractory to medications and
 have prostate sizes up to 80 g.
 Sterile urine should be verified before the
procedure.
 Local anesthesia—Office setting

36. Not recommended for patients with
 Metallic pelvic prostheses
 Defibrillator
 Pacemaker

37. TUNA-PREOPERATIVE
 Preprocedural TRUS…
 prostate size, anatomy & prostate width.
 Cystoscopy to
 rule out any bladder pathology and
 verify the distance from the bladder neck to
verumontanum.

38. TUNA vsTURP
 A meta-analysis of RCTs (Bouza et al, 2006)
concluded that
 TUNA and TURP were fairly equivalent in results at 3
months, with
 TURP providing superior results after that point.
 Maximum flow of the TURP group was at least
double the improvement seen in TUNA throughout
the entire analysis.

39. TUNA-COMPLICATIONS
 Intraoperative and Perioperative
0
20
40
60
80
100
Mild post-
procedural
hematuria
Irritative voiding
symptoms
Pain during
procedure
% 100 8 22
%

40.  Postoperative
0 10 20 30 40 50
UTI
Sexual dysfunction
Dysuria
Perineal pain
Pain medication
%
%
TUNA-COMPLICATIONS

41. 0
10
20
30
40
50
60
ED Decrease in
Ejaculation
Retrograde
Ejaculation
TUNA 0 13 0
TURP 12.7 54 41
%
Complications
TUNA vsTURP

42.  The researchers found that TUNA
 had a much higher rate of secondary procedures
(OR 7.4) compared with TURP but
 was safer with a lower rate of complications
(OR 0.14).
TUNA vsTURP

43. Conclusion-Role ofTUNA
 TUNA statistically improves symptoms
 But not as impressive as with TURP
 Negligible reduction in prostate volume
 Likely headed toward a minimal role
 Overall a very safe procedure but a less attractive
option among MISTs

44. TUIP
 Transurethral Incision of the Prostate
 The practice of incising the prostate or bladder
neck for reduction in voiding symptoms dates back
to 1834
 TUIP is an operative approach to disrupt the
prostatic capsule to alleviate voiding symptoms.

45. Ideal patient
a young man with
a small prostate <30g
who is concerned about either
a loss of ejaculation or
future fertility

46. TUIP vsTURP
 In a randomized study by Jahnson and colleagues (1998) in
prostates <27g ,
 TURP
 took longer than TUIP and
 had a larger estimated blood loss but
 did provide a larger improvement in postoperative Qmax.
 10 patients in the TUIP group required reoperation compared
with only 3 in the TURP group (P = .039)

47. TUIP-COMPLICATIONS
 Intra & Perioperative
 Significant hemorrhage
requiring transfusion—
0.9%
 Capsular perforation
 Temporary urinary
retention---11%
 Postoperative
 Lower risk of retrograde
ejaculation vs TURP
 Urethral stricture—2.9%
 Repeat prostatic
surgery—9.6%
 Incontinence/bladder
neck contracture--- <1%

48. TUIP Summary
 Reasonable option in a correctly selected patient.

49. 
LaserTreatments

50. LASER
 “light amplification by stimulated emission of
radiation.”
 Laser prostate treatments rely on the prostate
 interacting with the light energy and
 converting it to local thermal energy.

51. COAGULATION /VAPORIZATION
 Below the vaporization
temperature,
 the tissue proteins are
denatured,
 leading to coagulative
necrosis
 with delayed tissue
death and sloughing.
 Vaporization occurs
when the tissue is
heated above the
vaporization (boiling)
temperature,
 which leads to
intracellular water
vaporization and quick
tissue destruction.

52. Prostate Ablation &Vaporization
 KTP- & LBO-labeled lasers
 Wavelength of 532 nm.
 Selectively absorbed by hemoglobin ( PVP )
 As the power of the laser improved ( 80-180-W ),
the term ablation gradually migrated to
vaporization.

53. PVP Advantage
 Combined vaporization and coagulation.
 The tissue volume is decreased by the vaporization
 Coagulation leads to almost instantaneous
hemostasis with closure of venous sinuses, reducing
absorption of irrigation fluid.

54. PVP-Technique
Preoperative
 TRUS.. Prostate size
 To choose the treatment option
 Rough estimate of operative time
 Patients on antiplatelet medications
 To continue perioperatively.

56. PVP
 Shorter catheterization ( -
1.91 days )
 Shorter hospital stay ( -
2.13 days )
 Risk ratio for blood
transfusion..0.16
TURP
 Operative time shorter by
20 min

57. PVP-Complications
 Intra & Perioperative
 Capsular perforation ( 0.2%-1% )
 Convert to TURP.
 Ureteral orifice injury

58.  Postoperative
 Epididymitis ( 5%-7% )
 UTI ( 1%-20% )
 Reoperation rates
 Dysuria
 Temporary incontinence
PVP-Complications

59. PVP-Conclusion
 Essentially bloodless field
 Treatment of challenging patients such as those on
anticoagulation.

60. Holmium Prostate Enucleation
 The holmium:yttrium-aluminum-garnet (Ho:YAG)
laser
 emits light at 2140 nm
 has a pulsed instead of continuous energy emission.

61.  Historically, the holmium laser was used also for
holmium laser ablation of the prostate (HoLAP)
 Primarily it is now used to enucleate the prostate in
a procedure named holmium laser enucleation of
the prostate (HoLEP).

62.  A treatment with excellent results BUT
 A difficult and exaggerated learning curve has
consistently been seen in adopters of this
technique.
 More suitable for patients with a larger gland who
would previously have undergone OP.

63. HOLEP

64. HoLEP vsTURP
 Similar time efficiency (weight of adenoma
removed versus operating room time).
 Catheter time was also found to be shorter in the
HoLEP group.
 Statistical superiority in support of HoLEP with
regard to change in AUASS and Qmax.
 HoLEP was the only endoscopic procedure that has
shown superiority to TURP.

65. HoLEP vs Open Prostatectomy
 Operative time longer with HoLEP
 But no patients received transfusion in the HoLEP
group (compared with 13% in the OP group)
 HoLEP patients had shorter lengths of
hospitalization and catheterization.

66. HoLEP Complications
 Intra & Perioperative
 Morcellator-mediated
bladder injury
 Incomplete evacuation of
adenoma
 Injury to ureteral orifice-2.1%
 Capsular Perforation
 Hemorrhage requiring
transfusion—minimal with
RR of 0.27 vs TURP
 Postoperative
 Storage symptoms-common
 Transient urinary
incontinence---10.7%
 Bladder neck contracture-
smaller prostates
 Urethral stricture
 Retrograde ejaculation-75%

67. THULIUM
 Thulium:yttrium-aluminium-garnet ( Tm:YAG ) laser
 Continuous wave
 2013-nm

68. CONCLUSION
 OP & M-TURP---- Excellent treatment for LUTS &
BPH
 Gold standard operation for any patient should
 Meet his needs & expectations
 While still being safe
 Surgeon’s familiarity & ability to safely perform the
selected procedure

69. Prostate Stents

70.  The high failure and removal rates, with an often
difficult removal, were overall prohibitive.
 These frail older men were more likely to die with
their stent in situ (38%) than to require removal
(23%).

71. Prostate Urethral Lift

72.  Rigid Cystoscope sheath
 In the office settting
 Local anesthesia

74. Prostate Embolization

75. Prostatic Injections
Anhydrous ethanol
Botulinum toxin

77. ThankYou