Transurethral needle ablation of the prostate: a urodynamic based study with 2-year followup

A Scoping Review of the Management of Benign Prostate Hyperplasia in Africa

Benign prostatic hyperplasia (BPH) is a non-malignant prostate gland enlargement of unknown cause that affects more than 50% of men over 60 and is the most common cause of bladder outlet obstruction and voiding symptoms. BPH is treated primarily with watchful waiting, phytotherapy (herbs), and medical or surgical options. In this study, we sought to examine the different management practices in African urological centers, outcomes of management, and complications. A literature search was conducted using PubMed, African Journal Online, and Google Scholar regarding the management of BPH from inception till date. Articles were selected based on their relevance to the management of benign prostatic enlargement in Africa. Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. The studies included were conducted from 1997 to 2022. They were from eight different African countries (Nigeria, Kenya, Togo, Ethiopia, Egypt, South Africa, Ghana, and Congo), with Nigeria contributing the most with 10 studies. Exactly 2999 patients were included in the study. Seventy-three (73.49%) percent of these patients totaling 2204, underwent surgical management of BPH, 124 (4.13%) patients were treated with phytomedicines or herbs, and 684 (22.80%) patients were treated with medical therapy. The complications and outcomes were studied and collated. A total of 808 patients opted for non-surgical treatment for BPH in the included studies. In this group, 124 were treated using phytochemicals or natural herbs, and 648 were treated with standard prescription medications. While surgical treatment for benign prostatic enlargement is shifting towards minimally invasive procedures in the developed world, open prostatectomy is still quite popular in Africa. Further research should focus not only on the reason for these disparities in management but also on the rationale for the selection of medical, surgical, or phytotherapy in African urological centres.

Benign Prostatic Obstruction Relief in Patients with Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Enlargement Undergoing Endoscopic Surgical Procedures or Therapy with Alpha-Blockers: A Review of Urodynamic Studies

Benign prostatic obstruction (BPO) contributes to the genesis of lower urinary tract symptoms as well as to pathologic remodeling of the lower and upper urinary tract in patients with benign prostate enlargement. Urodynamic studies demonstrate that both medical therapy with alpha-blockers (ABs) and endoscopic surgical procedures provide BPO relief. However, the magnitude of improvement is higher after surgery. Among ABs, silodosin is associated with the highest improvement of bladder outlet obstruction index (BOOI). A complex relationship exists between BOOI improvement and variations of both maximum urinary flow (Q _max) and detrusor pressure. When the reduction of BOOI is small, the improvement of Q _max is clinically irrelevant and the BOOI is mainly influenced by a decrease of detrusor pressure. In contrast, when the magnitude of BOOI reduction is robust, a meaningful improvement of both detrusor pressure and urinary flow is evident. When clustering ABs according to their receptor pharmacologic selectivity and urodynamic efficacy, three subgroups can be identified,with silodosin being the only member of a subgroup characterized by the highest levels of BOOI improvement and α-1A/α-1B receptor affinity ratio.

[S2e guideline of the German urologists: Instrumental treatment of benign prostatic hyperplasia]

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the instrumental treatment of the lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding open and transurethral procedures (TUR-P, bipolar TUR-P, TUI-P, HE-TUMT, TUNA, and the different Laser techniques). Recommendations are also given concerning intraprostatic stents and injection therapies. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

Prospective short-term evaluation of transurethral needle ablation procedure in an ambulatory setting

OBJECTIVE

To assess the results of transurethral needle ablation (TUNA) (Prostiva®, Medtronic, France) performed in an ambulatory setting in men with lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A multicenter open-label study was conducted. Short-term success was defined by ability to leave the hospital on the evening of the intervention, and absence of rehospitalization due to complications during the first postoperative month. Sexual and urinary functions were evaluated by validated questionnaires.

RESULTS

The procedure was successful in 44/49 patients. Sexual and ejaculatory function was not affected or slightly improved in the majority of patients. Urinary parameters improved with a 32% decrease in the International Prostate Symptom Score. At 1 month postoperation, more than 80% of patients were satisfied, and 36/41 patients were prepared to undergo the procedure again if needed. Our study was limited by the short follow-up duration.

CONCLUSIONS

TUNA can be successfully performed in an ambulatory setting under local and/or general anesthesia with a high level of patient satisfaction and a low short-term morbidity, especially on sexual function. Thus, the procedure is a suitable mini-invasive option for patients who cannot/do not want to take medical therapy or undergo invasive surgical procedures, or want to preserve their sexual function.

[Treatment of benign prostatic hyperplasia by Prostiva(®): about a series of 76 cases]

PURPOSE

To evaluate the efficacy and morbidity of BPH treatment by radiofrequency in the general population and attempt to identify factors of prognostic value for this technique.

METHODS

This retrospective study examined 76 consecutive patients of mean age 68.9 years with symptomatic BPH in failure of medical treatment and treated at University Hospital of Caen between April 2004 and October 2008. Urine status was assessed before and after treatment with radiofrequency by the international prostate symptom score (IPSS), the quality of life (QOL) score related to urinary symptoms, the measurement of maximum urinary flow (Qmax) and residual postvoid volume (RPV). Erectile function was assessed by the International Index of Erectile Function (IIEF-5). The primary endpoint was treatment failure by radiofrequency regarded as the reintroduction of medical treatment or the need for surgical treatment. The secondary endpoints were the improvement of IPSS and QOL score, Qmax and RPV. Morbidity per and post-operative was also evaluated.

RESULTS

A significant improvement in voiding status was observed with an average IPSS score from 24.7 to 15.1 (P<0.0001), and a QOL score from 5.2 to 2.9 (P<0,0001) in all patients. The Qmax and the RPV were significantly improved from 8.6 to 13.1ml/s (P<0.0001) and 177 to 100ml (P=0.0002) respectively. The IIEF-5 score was improved from 9.04 to 9.97 (P=0.0164). Twenty-five percent of acute urinary retention, 7.9% of haematuria and 1.3% of prostatitis were observed postoperatively. The overall retreatment rate was 46% after 14.6 months mean follow-up. When stratified into groups, patients with the inclusion criteria to this treatment showed a treatment rates of 34.8% after 16.2 months mean follow-up against 51% after 13.8 months of monitoring patients outside the inclusion criteria. Without showing significant difference between retentionist and no retentionist concerning subjective and objective parameters, the rate of retreat was more important for retentionist (51.2% after 11.8 months of mean follow against 39.4% after 18.4 months) with a significant difference on the actuarial cumulative survival curve without reprocessing. There was no significant difference found in patients with a median lobe. The results showed an improvement in Qmax significantly greater in the group with prostates less than 60 g without being able to demonstrate significant differences in other parameters. The retreatment rates in this group was 44.4% after 14.7 months of follow-up against 53.8% after 13.8 months of follow-up in the group of patients with prostate over 60 g. Moreover, the irritative component made a better initial response to treatment with a need for retreatment delayed compared to the group of patients with obstructive symptom, without noting significant differences in terms of improvement of objective and subjective parameters. The rate of retreatment was 63.6% after 16.4 months of mean follow and 51.6% after 11.2 months in the "obstructive" group.

CONCLUSION

High rates of reprocessing are observed in the treatment of BPH by radiofrequency if inclusion criteria are not respected.

Measurement of benign prostatic hyperplasia treatment effects on male sexual function

Benign prostatic hyperplasia (BPH) is the leading cause of lower urinary tract symptoms among the aging male population. Epidemiological, pathophysiological and clinical studies indicate that many of these men also suffer from declining sexual function, especially those undergoing treatment for their BPH-related urinary symptoms. Although urinary symptoms and quality of life may improve with BPH therapy, the resulting effects on sexual function vary by medical, surgical and minimally invasive approaches and have not been consistently reported. As comprehensive, validated instruments to measure male sexual function are now available for routine use in the clinical setting, urologists and primary care providers caring for patients with BPH have the opportunity to monitor both urinary and sexual function before, during and after BPH therapy. Herein, we describe the relationship between BPH and its treatments on male sexual function, the role of new measures for sexual functioning and opportunities for future work to improve the care of men suffering from both maladies.

[Tuna: clinical retrospective study addressing mid-term outcomes]

PURPOSE

To estimate the efficiency and morbidity of the radiofrequency (Tuna) for treatment of symptomatic benign prostatic hyperplasia (BPH) in patients with medical treatment failure.

MATERIAL AND METHODS

Between September 2003 and July 2007, 31 patients, mean age 59,5 years (50-76), were treated for BPH with Tuna. Patients had initially received medical treatment, which happened to fail and Tuna was offered as surgical treatment. Available clinical data of 28 patients was retrospectively analyzed. Mictionnel status was estimated with International Prostatic Symptoms Score (IPSS), urinary peak flow (UPF) and post void residual urine (PVR). Quality of life issues were also addressed. Efficiency of treatment was estimated on the evolution of these parameters after an average follow-up of 20 months (5-47). To estimate morbidity of treatment, peroperative and late complications were assessed.

RESULTS

Twenty-eight patients were included in the study. At a mean follow-up of 20 months, a significant improvement of the mictionnel status was found for the IPSS, the quality of life, the Qmax (p<0,001) and the PVR (p<0,005) and quality of life. Morbidity was verified as minimal in the series. At a follow-up period of 20 months, 15 patients (53,6%) had stopped medical treatment, 10 patients (35,7%) pursued medical treatment and three patients (10,7%) had undergone another type of surgical treatment for BPH. The rate of re-treatment in the series was 46,4%. Among the group of patients without any medical treatment (15 patients), 10 patients reported satisfactory quality of life.

CONCLUSION

Tuna is a technique with significant good results for the treatment of LUTS-BPH. The main advantage of this technique is its low morbidity, however, the rate of retreatment was observed as high. Series of patients with long-term follow-up should provide evidence to objectively define the role of Tuna in BPH surgical treatment.

Characterizing TUNA ablative treatments of the prostate for benign hyperplasia with gadolinium-enhanced magnetic resonance imaging

BACKGROUND AND PURPOSE

Transurethral Needle Ablation of the prostate TUNA has been accepted as an office-based treatment for benign prostatic hyperplasia (BPH) for many years. Clinical outcomes have been reported, but the amount and location of the necrosis produced have yet to be characterized. The necrosis caused by TUNA was evaluated by gadolinium-enhanced magnetic resonance imaging (MRI) of the pelvis.

PATIENTS AND METHODS

Twelve patients with BPH/lower urinary-tract symptoms underwent standard TUNA, and MRI scans with gadolinium enhancement were performed before and 1 week after treatment. The images were studied using Analyze software to quantify the amount of necrosis compared with the prostatic volume. Transverse, coronal, and sagittal images were obtained to identify the location of the necrosis.

RESULTS

New gadolinium defects were seen in all patients after TUNA. The lesions coalesced into continuous areas of necrosis and correlated with the site of needle placement. The mean volume of necrosis was 6.84 cc and equated to 8.6% of the prostate volume. No lesions were found near the apex, urethra, or rectum; and none extended beyond the prostate capsule.

CONCLUSIONS

Gadolinium-enhanced MRI demonstrates new vascular defects representing necrosis caused by TUNA of the prostate. This therapy for BPH produces necrotic lesions that can be placed strategically by the surgeon. The standard protocol produces lesions that coalesce to create larger lesions. This MRI study has characterized, for the first time, the heating pattern and intraprostatic necrosis of a complete TUNA procedure.

Is the minimally invasive treatment as good as transurethral resection for benign prostatic hyperplasia?

Despite the development of new technologies, transurethral resection of the prostate (TURP) is still considered the gold standard for surgical treatment of the benign prostate hyperplasia (BPH). In general, new minimally invasive treatments have not demonstrated better outcomes than TURP in evidence based medicine trials published to date, and should be reserved for patients who prefer to avoid surgery, who are unsuitable candidates for surgery or who no longer respond favorably to medication. TUMT and TUNA appears to be more effective than medical therapy but less effective than TURP. Both treatments can be given under topical anesthesia or local prostatic or perineal block. Efficacy of transurethral vaporization appears similar to TURP, but the studies are short-term and the glands operated on are relatively small. In patients with small prostates, the transurethral incision of the prostate can also be a good option, associated with less morbidity than TURP. Bipolar resection of the prostate is similar to TURP in effectiveness, but the data are inconclusive regarding blood loss, length of catheterization and hospital stay. Long-term comparative trials are needed to determine if the minimally invasive therapies are superior to standard TURP.

Transurethral needle ablation of the prostate

PURPOSE OF REVIEW

The review aims at reviewing the evidence published in the peer review literature or otherwise available with particular focus on articles published over the last 2 years on the transurethral needle ablation of the prostate in the treatment of benign prostatic hyperplasia. Prospective noncomparative and comparative studies as well as meta-analyses were considered. Information from the European Real Life database on transurethral needle ablation was also included.

RECENT FINDINGS

The evidence currently available confirms a clinically relevant improvement of lower urinary tract symptoms and quality of life. Impact on voiding dynamics including flow rates, detrusor pressure at maximum flow and postvoid residual, as well on prostate volume, remains marginal.

SUMMARY

All major guidelines in the management of lower urinary tract symptoms in patients with benign prostatic enlargement include transurethral needle ablation of the prostate as a valuable treatment option in patients with severe symptoms and low degree of bladder outlet obstruction, patients at high risk for surgery and patients who wish to avoid surgery or regional/general anaesthesia.

Comorbid LUTS and erectile dysfunction: optimizing their management

BACKGROUND AND SCOPE

Lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH), and sexual dysfunction such as erectile dysfunction (ED), are highly prevalent in men over the age of 50. LUTS and ED have a negative impact on sexual function and when comorbid, result in reduced quality of life. The goal of this article is to discuss the relationship between ED and LUTS, describe the diagnostic workup of these disorders, explore the current treatment options, and examine how treatments may affect this population. Medline (1980-2006), Cochrane reviews, and the American Urological Association 2006 General Meeting abstracts were searched for relevant clinical trials and reviews with the terms: benign prostatic hyperplasia, lower urinary tract symptoms, erectile dysfunction, sexual dysfunction, alpha-adrenergic receptor antagonists, alpha-blockers, 5alpha-reductase inhibitors, phosphodiesterase type-5 inhibitors, transurethral resection of the prostate, transurethral microwave thermotherapy, transurethral needle ablation, adverse events, alfuzosin, doxazosin, tamsulosin, terazosin, dutasteride, finasteride, sildenafil, tadalafil, vardenafil. However, because of the volume of literature, this article is not a systematic review.

FINDINGS

Although age is an independent risk factor for both LUTS and ED, studies report that LUTS is also an independent risk factor for ED. Treatments for LUTS include pharmacologic, minimally invasive, and surgical therapies. Among pharmacologic options, alpha1-adrenergic receptor (alpha1-AR) antagonists provide effective treatment with a low risk of sexual side-effects; some of these drugs have been reported to improve sexual function. The treatment of LUTS may improve ED. Phosphodiesterase type 5 inhibitors (PDE-5s) are considered first-line therapy for ED. Comorbid LUTS and ED are treated with an alpha1-AR antagonist and a PDE-5; however, this combination must be used with caution because of vasodilatory adverse events associated with both classes of drugs.

CONCLUSIONS

Optimal management includes screening to identify patients with comorbid LUTS and ED, and the use of treatments that minimize both vasodilatory and sexual side-effects.

How do I treat and follow my TUNA patients

Transurethral needle ablation (TUNA) of the prostate is an alternative treatment for benign prostatic hyperplasia (BPH) generating temperatures around 100 degrees C leading to necrotic lesions inside the prostate. TUNA is a minimally invasive, low morbidity associated, approach that uses radiofrequency energy. The needles are covered by teflon shields that protect the urethra from thermal injury. Since the introduction of TUNA, there has been a constant upgrading of the device to improve treatment quality. The main advantage of this therapy is the possibility of an outpatient care due to its anaesthesia-free option with a prostatic block. Catheterisation after the procedure is required in 10-40% of cases. Long-term data (5 years) on TUNA demonstrate a sustained improvement of both IPSS score and urinary flow. About a quarter of patients require further intervention at 5 years' follow-up. The safety profile, along with the significant improvement in both objective and subjective parameters observed after TUNA, makes it an attractive approach for symptomatic BPH.

Systematic review and meta-analysis of Transurethral Needle Ablation in symptomatic Benign Prostatic Hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) constitutes a major clinical problem. Minimally invasive therapies for the treatment of symptomatic BPH include Transurethral Needle Ablation (TUNA), but it is unclear what impact this technique has on the disease and its role among other currently available therapeutic options. The objective of this study is to ascertain the efficacy and safety of TUNA in the treatment of BPH.

METHODS

Systematic review of the literature until January 2005 and meta-analysis of clinical studies assessing TUNA in symptomatic BPH. Studies were critically appraised. Estimates of effect were calculated according to the random-effects model.

RESULTS

35 studies (9 comparative, 26 non-comparative) were included. Although evidence was limited by methodological issues, the analysis of relevant outcomes indicates that while TUNA significantly improves BPH parameters with respect to baseline, it does not reach the same level of efficacy as TURP in respect to all subjective and objective variables. Further, its efficacy declines in the long-term with a rate of secondary-treatment significantly higher than of TURP [OR: 7.44 (2.47, 22.43)]. Conversely, TUNA seems to be a relatively safe technique and shows a lower rate of complications than TURP [OR:0.14 (0.05, 0.14)] with differences being particularly noteworthy in terms of postoperative bleeding and sexual disorders. Likewise, TUNA has fewer anesthetic requirements and generates a shorter hospital stay than TURP [WMD: -1.9 days (-2.75, -1.05)]. Scarce data and lack of replication of comparisons hinder the assessment of TUNA vs. other local therapies. No comparisons with medical treatment were found.

CONCLUSION

The body of evidence on which TUNA has been introduced into clinical practice is of only moderate-low quality. Available evidence suggest that TUNA is a relatively effective and safe technique that may eventually prove to have a role in selected patients with symptomatic BPH. TUNA significantly improves BPH parameters with respect to baseline values, but it does not reach the same level of efficacy and long-lasting success as TURP. On the other hand, TUNA seems to be superior to TURP in terms of associated morbidity, anesthetic requirements and length of hospital stay. With respect to the role of TUNA vis-à-vis other minimally invasive therapies, the results of this review indicate that there are insufficient data to define this with any degree of accuracy. Overall cost-effectiveness and the role of TUNA versus medical treatment need further evaluation.

Fact or fiction: what do the benign prostatic hyperplasia data tell us?

Benign prostatic hyperplasia (BPH) is the most common benign neoplasm in men. Our understanding of this condition has improved greatly over the years and recent advances have changed our approach to management. At the end of the 19th century, prostatic enlargement was treated effectively by bilateral orchidectomy. Unsurprisingly, this treatment option never gained widespread popularity. Less than 10 years ago, surgery and watchful waiting were the only considered treatment options for BPH. We now have a number of medical therapies and minimally invasive treatment options available that can effectively manage lower urinary tract symptoms secondary to benign prostatic obstruction. However, with increased choice comes the increased need for clarity in selection and application of these various treatment options. In the current environment of evidence-based clinical practice, awareness and interpretation of data from the numerous studies is paramount. The lessons learned from these trials should be reflected clearly in our practice, with clinical management based on fact, not fiction. In this review, we critically assess the available data and understanding of the management of BPH.

Transurethral needle ablation versus transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia: 5-year results of a prospective, randomized, multicenter clinical trial

PURPOSE

We report the 5-year efficacy and safety of transurethral needle ablation of the prostate (TUNA) compared to transurethral resection of the prostate (TURP) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A total of 121 men 50 years or older with LUTS secondary to BPH a minimum of 3 months in duration were enrolled in this prospective, randomized clinical trial at 7 medical centers across the United States. Of the participants 65 (54%) were randomly selected to receive TUNA and 56 (46%) were selected to receive TURP. International Prostate Symptom Score, quality of life, peak urinary flow rate, post-void residual urinary volume, and prostate size and configuration were evaluated before the procedure and then annually for 5 years after the procedure. Adverse events were also recorded throughout the study.

RESULTS

Improvement from baseline for TUNA and TURP retained statistical significance at each interval for International Prostate Symptom Score, quality of life and peak flow rate. Post-void residual volume was statistically significant at all time points for TURP and at year 5 for TUNA. The TURP group reported 41% retrograde ejaculation, while the TUNA group reported none. The incident of erectile dysfunction, incontinence and stricture formation was also greater in TURP than in TUNA cases with significantly fewer adverse events for TUNA than for TURP.

CONCLUSIONS

The results of this study demonstrate stable treatment outcomes after 5 years of followup and suggest that TUNA is an attractive treatment option for men with LUTS due to BPH.

A meta-analysis of trials of transurethral needle ablation for treating symptomatic benign prostatic hyperplasia

OBJECTIVES

To investigate the short- and long-term effectiveness of transurethral needle ablation (TUNA) of the prostate for clinical benign prostatic hyperplasia (BPH), using a meta-analysis of all clinical studies involving TUNA.

METHODS

Data were extracted from two randomized trials, two non-randomized observational protocols and 10 single-arm studies conducted on TUNA, according to a determined protocol. The meta-analysis was based on the change in the mean score at the end of study from that at baseline. The estimation of the effects from the meta-analysis used a multilevel model including random effects for the studies.

RESULTS

In all studies the patients recruited had severe lower urinary tract symptoms and a mean International Prostate Symptom Score (IPSS) of > 20 before treatment. The effect of TUNA was to halve the mean IPSS at 1 year after treatment and, although there was a slight tendency for the IPSS to increase in all arms from year 1 to year 5, this decrease by half was maintained at 5 years. The maximum urinary flow rate (Q(max)) also increased by approximately 70% from baseline to 1 year and in virtually all studies the mean Q(max) approached or exceeded 15 mL/s. Although there was a tendency for Q(max) to decline slightly over time, the mean Q(max) 5 years after treatment was > 50% over baseline.

CONCLUSIONS

This meta-analysis shows that TUNA is an effective and minimally invasive treatment for men with clinical BPH, even when the symptoms are severe. There is a significant improvement in symptoms and flow rate after 1 year which persists for at least 5 years. TUNA therapy would appear to be an alternative to surgery and an attractive option for men who do not wish to undergo long-term medical therapy, are poor candidates for surgery or are concerned about the side-effects of TURP.

Lower urinary tract symptoms and erectile dysfunction: co-morbidity or typical "Aging Male" symptoms? Results of the "Cologne Male Survey"

OBJECTIVES

Due to demographic developments in industrial nations, age-correlated diseases are becoming more important. From many epidemiological studies we know that the prevalence of benign prostatic hyperplasia (BPH) and the loss of erectile function (= erectile dysfunction or ED) increase with advancing age. Are these two illnesses related or/and independent?

METHODS

We mailed our newly developed and validated questionnaire on male erectile dysfunction (KEED), as well as a set of questions pertaining to voiding problems (IPSS), to a representative population sample of 8000 men from 30 to 80 years of age residing in the city of Cologne.

RESULTS

The responses included 4489 evaluable replies (56.1%). The response rates in the different age groups ranged from 41 to 61%. The mean age of the men who answered was 51.8 years. The overall prevalence of ED was 19.2% (n=862), with a steep age-related increase from 2 to 53%. Furthermore, 31.2% (n=1957) of all men complained of lower urinary tract symptoms (LUTS), the prevalence and the intensity of which increased with age. Interestingly, a high co-morbidity was found between ED and voiding problems. Prevalence of LUTS in men suffering from ED was about 72.2% (n=621) vs. 37.7% (1367) in men with normal erections. The odds ratio was evaluated with 2.11. The trivariate analysis showed that the occurrence of LUTS can be considered as an age-independent risk factor for the development of ED (p<0.001).

CONCLUSIONS

Even though the pathogenetic relationship between LUTS and ED is not yet completely understood, one has to postulate a direct association between these two typical symptom complexes in the aging male.

Cholinergic innervation and function in the prostate gland

The mammalian prostate is densely innervated by hypogastric and pelvic nerves that play an important role in regulating the growth and function of the gland. While there has been much interest in the role of the noradrenergic innervation and adrenoceptors in prostate function, the role of cholinergic neurones in prostate physiology and pathophysiology is not well understood. This review focuses on the role of acetylcholine and cholinoceptors in prostate function. Nitric oxide, vasoactive intestinal polypeptide, and/or neuropeptide Y are co-localised with cholinesterase and/or acetylcholine transporter in some of the nerve fibres supplying the prostate. Their roles are also briefly discussed in this review. A dense network of cholinesterase-staining fibres supplies both prostate epithelium and stroma, suggesting a role of acetylcholine and/or co-localised neuropeptides in the modulation of prostatic secretions, as well as smooth muscle tone. A predominantly epithelial location for prostate muscarinic receptors indicated a major secretomotor role for acetylcholine. The muscarinic receptor subtype mediating muscarinic agonist-induced smooth muscle contraction or enhancement of contractions evoked by nerve stimulation differs in different species. In the human, there is evidence for M(1) receptors on the epithelium, M(2) receptors on the stroma, and both M(1) and M(3) receptors in some prostate cancer cell lines. Several recent investigations indicate that muscarinic receptors may also mediate or modulate normal, benign, and malignant prostate growth. The role of muscarinic agonists and their receptors and the influences of age, testicular, and other steroids in regulating the effects are reviewed.

Transurethral needle ablation of the prostate: an initial Japanese clinical trial

OBJECTIVES

Transurethral needle ablation of the prostate is a new alternative endoscopic thermal therapy that uses a low-energy radio frequency delivered into the prostatic adenoma. Herein is reported the initial clinical experience by multiple institutes in Japan of transurethral needle ablation of the prostate for the treatment of symptomatic benign prostatic hyperplasia.

METHODS

A total of 93 patients were treated with this technique. Transurethral needle ablation of the prostate was generally performed under low-spinal anesthesia. Before and after the procedure, international symptom score (IPSS), quality of life (QOL) score, peak urinary flow rate (Qmax), postvoid residual urine volume and prostate size were evaluated.

RESULTS

There was a reduction of IPSS of more than 50% when compared with that of pretreatment, being 51.3% (57/93 patients) and 60.2% (56/93 patients) at 3 months and 6 months after the procedure, respectively. Sixty-seven patients who were available for a 12-month follow-up period demonstrated a markedly decreased mean IPSS when compared with that measured before the treatment for a statistically significant difference (P < 0.01). Fifty-eight patients who were available for uroflowmetric study at 12 months exhibited a notably increased mean Qmax of 11.2 +/- 4.5 mL/s, which was a statistically significant increase when compared with that found before treatment (P < 0.05). Although all patients suffered some degree of gross hematuria after the procedure, none of them required any specific treatment for complications.

CONCLUSION

Transurethral needle ablation technique for the treatment of symptomatic benign prostatic hyperplasia is safe and effective. However, a much longer follow-up study is essential for fully evaluating the extended effectiveness of this technique.

Changing therapeutic regimens in benign prostatic hyperplasia. Clinical and economic considerations

About one-quarter of men aged 50 years and older experience voiding problems due to benign prostatic hyperplasia (BPH). Until about 10 years ago, surgery (particularly transurethral resection of the prostate) was the only effective treatment for symptomatic BPH. Over the last decade, several new treatments have been introduced. These include different types of medication (alpha-blockers and finasteride), thermotherapy, laser prostatectomy, needle ablation and vaporisation methods. The diffusion of these less invasive treatment modalities has resulted not only in a decrease in the age-adjusted surgery rates, but also in an increase of the total number of men treated for BPH. A large number of studies on clinical benefits and risks reveal that the conventional types of surgery remain the most effective treatments, whereas new interventional therapies require a shorter hospital stay and result in fewer short term complications. The efficacy of medication is lower than that of interventional treatments. Adverse effects include dizziness and orthostatic hypotension (alpha-blockers) and decreased sexual function (finasteride), but are generally mild. There is some evidence that medication and minimally invasive treatments may preclude eventual surgical treatment, but the precise effect is difficult to estimate because of differences in the study populations and the relatively short study periods. As a result of the dynamic nature of BPH treatment and the lack of long term data, the cost effects of the introduction of the various new treatments are also difficult to assess. Given the aging of the population and the growing percentage of patients with BPH for whom any type of treatment can be considered, a considerable increase of total costs can be expected. Long term prospective studies are necessary to gain insight into the most cost-effective treatment for different patient groups.

Transverse prostate measurement obtained using transabdominal ultrasound: possible role in transurethral needle ablation of the prostate

OBJECTIVES

To correlate the maximal transverse prostate measurement determined using transabdominal ultrasound with the maximal transverse prostate measurement determined using transrectal ultrasound.

METHODS

The records of 287 patients who had undergone both transabdominal pelvic ultrasound for determination of postvoid residual urine volume and transrectal ultrasound for evaluation of elevated serum prostate-specific antigen levels or abnormal digital rectal examinations were reviewed. For all patients, the maximal transverse prostate dimension had been recorded at each study. Linear regression analysis was used to correlate these two data sets.

RESULTS

There was a strong correlation between the maximal transverse prostate dimension determined using transabdominal ultrasound and that determined using transrectal ultrasound. The R(2) for the regression analysis was 0.448. From the regression analysis, the equation that converts the maximal transabdominal transverse prostate measurement into its equivalent transrectal counterpart was determined: transrectal measurement (cm)=0.5109 [transabdominal measurement (cm)]+2.2935.

CONCLUSIONS

A strong mathematical correlation was found between the maximal transverse prostate dimension determined using transabdominal ultrasound and that obtained using transrectal ultrasound. This may have clinical significance when performing transurethral needle ablation of the prostate.

Transurethral needle ablation of the prostate: outcome at 1 year

BACKGROUND

Urologists continue to search for alternatives to transurethral prostatectomy that carry a lower potential for complications.

PATIENTS AND METHODS

Twenty-five patients on the public waiting list for transurethral resection of the prostate, all spontaneously voiding, underwent transurethral needle ablation of the prostate (TUNA). Eight patients had a simultaneous bladder neck incision (BNI). Follow-up with International Prostate Symptom Scores and flow rate measurement was performed at 6 weeks, 7 months, and 1 year.

RESULTS

A statistically significant increase in flow rate and fall in symptom scores occurred out to 1 year after TUNA. Despite this result, six patients (24%) were not satisfied with their outcome and underwent a second endoscopic operation.

CONCLUSION

In our hands, TUNA produced an unsatisfactory clinical result.

The effects of transurethral needle ablation and resection of the prostate on pressure flow urodynamic parameters: analysis of the United States randomized study

PURPOSE

We evaluated the effects of transurethral needle ablation and prostate resection on pressure flow urodynamic parameters in men with benign prostatic hyperplasia (BPH), compared symptomatic and objective parameters of efficacy 6 months after initial treatment, and determined whether urodynamic assessment may predict symptomatic improvement.

MATERIALS AND METHODS

We enrolled 121 patients with clinical BPH, American Urological Association symptom index of 13 or greater and maximum urinary flow of 12 ml. per second or less in a randomized study comparing transurethral needle ablation to prostate resection at 7 institutions in the United States. Patients underwent baseline and followup assessments at 6 months, including pressure flow studies.

RESULTS

Patients who underwent each procedure had statistically and clinically significant improvement in symptom index, BPH impact index and quality of life score. After needle ablation and prostate resection maximum flow improved from 8.8 to 13.5 (p<0.0001) and 8.8 to 20.8 ml. per second (p<0.0001), detrusor pressure at maximum flow decreased from 78.7 to 64.5 (p = 0.036) and 75.8 to 54.9 cm. water (p<0.001), and the Abrams-Griffiths number decreased from 61.2 to 37.2 (p<0.001) and 58.3 to 10.9 (p<0.001), respectively. At 6 months the differences in transurethral needle ablation and prostate resection were significant in terms of maximum flow (p<0.001) and the Abrams-Griffiths number (p<0.001) but not detrusor pressure at maximum flow or symptom assessment tools. The presence or absence of urinary obstruction at baseline did not predict the degree of symptomatic improvement in either treatment group.

CONCLUSIONS

Transurethral needle ablation and prostate resection induce statistically and clinically significant improvement in various quantitative symptom assessment questionnaires at 6 months. The parameters of free flow rates and invasive pressure flow studies also significantly improve after each treatment. However, transurethral prostate resection induces a significantly greater decrease in the parameters of obstruction. Baseline urodynamic parameters do not predict the degree of symptomatic improvement and they may not be helpful in patient selection for transurethral needle ablation.