The prostatron transurethral microwave device in the treatment of bladder outflow obstruction due to benign prostatic hyperplasia

[Sexual consequences of BPH treatments]

OBJECTIVE

To review the literature on the sexual adverse effects of pharmacological, instrumental and surgical treatments of lower urinary tract symptoms related to benign prostatic hyperplasia (LUTS/BPH).

METHOD

A non-systematic review of the scientific literature was conducted from the PubMed database to retrieve the most relevant scientific publications. A first research was cross-referenced with the results of literature reviews already published and enriched by the authors of this review.

RESULTS AND CONCLUSION

Sexual dysfunction and SBAU/BPH are intimately linked by a cross-over effect in the population of men over 50, a possible common pathophysiology and treatments for BPH with sexual consequences. Evaluating the sexuality of patients in care for SBAU/BPH is therefore essential. Patients should be informed of potential adverse drug effects of BPH, including ejaculation disorders with alpha blockers and loss of libido and erectile dysfunction with 5 alpha reductase inhibitors. After BPH surgery, loss of antegrade ejaculation is common, although preservation possibilities exist. The improvement of urinary function and the decrease of possible ejaculatory pains have a beneficial effect on the sexuality of the BPH patients operated. More rarely, patients may experience orgasmic dysfunction or even erectile dysfunction with a possible thermal effect on the vasculo-nerve bundles.

LEVEL OF EVIDENCE

Consensus d'experts.

Sexual Side Effects of Medical and Surgical Benign Prostatic Hyperplasia Treatments

Treatments for lower urinary tract symptoms due to benign prostatic hyperplasia can be evaluated by multiple metrics. A balance within the confines of patient expectations is key to determining the ideal treatment. A troubling adverse event for some patients is sexual dysfunction. Because the cohort of men who seek treatment of sexual dysfunction and lower urinary tract symptoms is essentially identical, these disease processes frequently overlap. This article considers potential pathophysiologic causes of dysfunction with treatment and attempts to critically review the available data to assess the true incidence of sexual adverse events with treatment.

Interstitial laser coagulation versus transurethral prostate resection for treating benign prostatic obstruction: a randomized trial with 2-year follow-up

OBJECTIVES

To investigate whether interstitial laser coagulation (ILC) is as effective and as safe as transurethral resection of the prostate (TURP). The treatment of choice for bladder outflow obstruction secondary to benign prostatic hyperplasia is TURP. However, ILC is a less invasive outpatient procedure that may be as effective and safe as TURP.

METHODS

In a multicenter randomized trial at six U.S. tertiary care hospitals, we treated 72 men with bladder outflow obstruction secondary to benign prostatic hyperplasia with either TURP (n = 35) or ILC (n = 37). The outcome measures were peak flow rate, postvoid residual urine volume, prostate volume, prostate-specific antigen levels, symptom and quality-of-life indexes, sexual function, and adverse event rates. Measurements were taken at baseline and at 3, 6, 12, and 24 months.

RESULTS

At 2 years, the TURP patients had better median peak flow rates, but not significantly so (range 16.5 to 13.9 mL/s, 95% confidence interval for the 2.6 mL/s difference of -0.4 to 7.6). The median scores on the symptom indexes and quality-of-life measures were similarly improved in both groups. Of 37 ILC patients, 6 (16%) were retreated with TURP in the first year. Sexual function declined in the TURP group but remained stable in the ILC group. The adverse event rates were similar, although the events were more serious in the TURP group.

CONCLUSIONS

ILC compares respectably with TURP. Given the advantages of an outpatient procedure, similar results in symptom reduction and quality-of-life measures, and less severe adverse effects, ILC can be an acceptable alternative to TURP.

Do prostatic stents solve the problem of retention after transurethral microwave thermotherapy?

Temporary nonmetallic stents offer an alternative to an indwelling catheter for the management of voiding problems after heat-based therapies for benign prostatic hyperplasia. Patient comfort is improved, and they are able to void immediately after the procedure. Unlike a catheter, stents function on the principle of active drainage. Thus, a functioning detrusor muscle is imperative for stent success. Single-center clinical trials have reported encouraging results; however, predictable success criteria are yet to be established. Multicenter trial data are awaited.

Transurethral microwave thermotherapy: symptom relief v urodynamic changes

Transurethral microwave thermotherapy (TUMT), whether in its low- or high-energy form, seems to reduce the symptoms of benign prostatic hyperplasia, with low-energy treatment resulting in less improvement than high-energy treatment. Low-energy TUMT has a minimal effect on bladder outlet obstruction, as judged by urodynamic findings, and may not be suitable to treat those patients with significant obstruction. High-energy TUMT does seem to relieve obstruction significantly, although it is not as effective as TURP. Urodynamic studies may provide the answer as to which therapy to offer the patient.

Transurethral microwave thermotherapy in benign prostatic hyperplasia

This article reviews the available literature and data on high-energy transurethral microwave therapy (TUMT) in the treatment of benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS). TUMT is a safe, durable, (1-hour) procedure, without the need for anesthesia. Emphasis is made on the effect and mechanism of TUMT, the different devices available including different energy protocols, and accompanying clinical results.

Transurethral microwave thermotherapy: what role should it play versus medical management in the treatment of benign prostatic hyperplasia?

Both transurethral microwave thermotherapy (TUMT) and medical management by alpha-blockade or 5-alpha-reductase inhibition are increasingly being considered as alternatives to surgery for treatment of patients with benign prostatic hyperplasia (BPH). We review current evidence supporting the effectiveness and safety of TUMT and medical management. Factors for consideration in appropriately selecting patients for TUMT versus medical management are suggested. Available data indicate that TUMT confers greater long-term benefits than medical management as judged by symptom score and peak urinary flow rate improvements. TUMT-associated morbidity is comparatively low. Alpha-blockade affords more rapid relief than TUMT for patients with BPH; however, other strategies such as the use of temporary intraurethral endoprostheses during the acute post-TUMT recovery period may diminish or abolish the differences in time-course of symptom and flow rate improvement between TUMT and alpha-blockade. 5-Alpha-reductase inhibition with finasteride offers a favorable side-effect profile, although the magnitude of symptom and flow rate improvements is modest, and maximal effects of finasteride do not become manifest until after several months of treatment. As TUMT continues to evolve, increasing attention is being accorded the delivery of high thermal doses and precise targeting of the thermal energy delivered. The development of alpha-blockers with a more favorable side-effect profile continues to be a major focus of investigation. The potential clinical utility of combination therapy with TUMT and alpha-blockade is currently under investigation.

Long-term follow-up of transurethral microwave thermotherapy

OBJECTIVES

To evaluate the long-term results of transurethral microwave thermotherapy (TUMT) for benign prostatic hyperplasia (BPH) with up to 5 years of follow-up at our institution.

METHODS

From October 1991 to November 1993, 106 patients were treated for BPH with TUMT using the Prostatron 2.0. Of the 106 patients, 64 were available for evaluation of symptoms (Madsen-Iverson score), uroflow, residual urine, and retreatment rate at a mean follow-up of 50+/-5.4 months (mean+/-SD).

RESULTS

The mean age of the patients was 65.2+/-9.8 years. Thirty-two patients (50.0%) were treated with one session of TUMT. Additional treatments were required for 32 patients (50.0%). Three patients had two sessions of TUMT, 14 underwent transurethral resection of prostate, and 3 had laser prostatectomy. Twelve patients received medical therapy. The mean symptom score decreased significantly from 12.9+/-2.5 to 5.7+/-3.6 (P = 0.001). The mean peak flow rates and postvoid residual volume showed little difference before and after TUMT. On the basis of the criteria described by Poincelet and Cathaud the overall clinical efficacy rate was 39.1% (15.6% complete response and 23.5% partial response). No obvious clinical parameter was useful to predict favorable outcome after TUMT.

CONCLUSIONS

The present study showed that the efficacy rate of TUMT with the Prostatron 2.0 at 50 months was 39.1 %. None of the preoperative clinical factors was predictive of a favorable outcome.

Office treatment of benign prostatic hyperplasia

The less invasive procedures described herein are suitable for use in the office setting. Improvement in symptoms and quality of life are similar to that achieved with TURP. With the exception of TUIP, flow rate improvement is less than with TURP. TURP, however, tends to produce a "super normal" flow rate, which may be unnecessary. Patients are concerned regarding symptoms and quality of life and the avoidance of complications. In regard to decreased complications, less invasive procedures have an advantage. The main concern with these new treatments, with the exception of TUIP, is durability. Treatment failure may lead to other treatments, thereby increasing overall management costs. In this regard, it must be remembered that there is a significant treatment failure rate with TURP. Although patients failing less invasive treatments are likely to be offered other treatments, this is less likely after an adequate TURP. Therefore, when results are compared, it may be more appropriate to evaluate failure rates based on symptoms and quality of life rather than on the use of additional treatments. More patient follow-up for a longer period of time will be required before a definite answer is available on durability. All of the procedures described herein can be performed to a variable extent using topical anesthesia. TUNA has been performed using topical lidocaine alone but frequently requires intravenous sedation/analgesia and, in some instances, a regional block. If the patient can tolerate rigid cystoscopy fairly well, topical anesthesia alone may suffice. Similar requirements for anesthesia apply to ILC with the Nd:YAG or indigo systems. Using the Targis (T3) microwave device, Peterson and co-workers reported that 60% of patients were treated with topical urethral lidocaine alone, whereas 40% also received oral Toradol. Djavan (personal communication) using the Targis (T3) device randomized patients to topical urethral anesthesia alone or combined with intravenous sedoanalgesia. Pain was evaluated using a 0 to 10 visual analog scale score. At the commencement of treatment, the mean score was 1.4 in the topical anesthesia alone group and 1.3 in the sedoanalgesia group. During therapy, the score increased to a peak at 30 minutes of 2.2 and 2.0 in the topical and sedoanalgesia groups, respectively. After this, the visual analog score declined, falling to 0.2 and 0.1, respectively, by 1 hour following treatment. This study shows that microwave treatment with the Targis (T3) system is well-tolerated using topical urethral anesthesia alone. No difference was observed between outcomes in the two groups. Capital and operating costs as well as reimbursement issues are important in the introduction of these treatments into the office; however, until more information is available on the durability of results, the cost-effectiveness of these newer treatments remains unclear.

Tolerability of high energy transurethral microwave thermotherapy with topical urethral anesthesia: results of a prospective, randomized, single-blinded clinical trial

PURPOSE

We determine the tolerability of high energy transurethral microwave thermotherapy with topical urethral anesthesia alone without supplementary systemic sedoanalgesia.

MATERIALS AND METHODS

A total of 45 patients with symptomatic benign prostatic hyperplasia were randomized to high energy transurethral microwave thermotherapy using either topical urethral anesthesia alone (topical anesthesia group) or topical anesthesia with adjunctive intravenous sedoanalgesia (sedoanalgesia group). Pain was evaluated sequentially by means of a 0 to 10 visual analog scale score. Posttreatment followup included determinations of International Prostate Symptom Score, peak flow rate, post-void residual urine, and quality of life score at 6 and 12 weeks.

RESULTS

Upon commencement of microwave treatment mean visual analog scale score was 1.3 (95% confidence interval [CI], 1.0 to 1.7) in the sedoanalgesia group and 1.4 (95% CI, 1.0 to 1.9) in the topical anesthesia group. During therapy visual analog scale score increased to a peak at 30 minutes of 2.0 (95% CI, 1.6 to 2.4) and 2.2 (95% CI, 1.7 to 2.6) in the sedoanalgesia and topical anesthesia groups, respectively. Thereafter, visual analog scale score continuously declined, falling to 0.1 (95% CI, 0.0 to 0.2) and 0.2 (95% CI, 0.0 to 0.3) in the 2 respective groups by 1 hour following conclusion of the treatment period. There was no statistically significant difference between the groups in the treatment profile of visual analog scale scores (p = 0.701). Significant posttreatment improvements were demonstrated in International Prostate Symptom Score, peak flow rate, post-void residual urine and quality of life scores but there were no significant differences between the groups in the magnitude of improvement in these outcome measures.

CONCLUSIONS

High energy transurethral microwave thermotherapy is well tolerated by patients under topical anesthesia alone and, therefore, can be administered in the outpatient setting without potent medications that necessitate intensive patient monitoring, pose risks for side effects and add to treatment costs.

Tolerability of high energy transurethral microwave thermotherapy with topical urethral anesthesia: results of a prospective, randomized, single-blinded clinical trial

PURPOSE

We determine the tolerability of high energy transurethral microwave thermotherapy with topical urethral anesthesia alone without supplementary systemic sedoanalgesia.

MATERIALS AND METHODS

A total of 45 patients with symptomatic benign prostatic hyperplasia were randomized to high energy transurethral microwave thermotherapy using either topical urethral anesthesia alone (topical anesthesia group) or topical anesthesia with adjunctive intravenous sedoanalgesia (sedoanalgesia group). Pain was evaluated sequentially by means of a 0 to 10 visual analog scale score. Posttreatment followup included determinations of International Prostate Symptom Score, peak flow rate, post-void residual urine, and quality of life score at 6 and 12 weeks.

RESULTS

Upon commencement of microwave treatment mean visual analog scale score was 1.3 (95% confidence interval [CI], 1.0 to 1.7) in the sedoanalgesia group and 1.4 (95% CI, 1.0 to 1.9) in the topical anesthesia group. During therapy visual analog scale score increased to a peak at 30 minutes of 2.0 (95% CI, 1.6 to 2.4) and 2.2 (95% CI, 1.7 to 2.6) in the sedoanalgesia and topical anesthesia groups, respectively. Thereafter, visual analog scale score continuously declined, falling to 0.1 (95% CI, 0.0 to 0.2) and 0.2 (95% CI, 0.0 to 0.3) in the 2 respective groups by 1 hour following conclusion of the treatment period. There was no statistically significant difference between the groups in the treatment profile of visual analog scale scores (p = 0.701). Significant posttreatment improvements were demonstrated in International Prostate Symptom Score, peak flow rate, post-void residual urine and quality of life scores but there were no significant differences between the groups in the magnitude of improvement in these outcome measures.

CONCLUSIONS

High energy transurethral microwave thermotherapy is well tolerated by patients under topical anesthesia alone and, therefore, can be administered in the outpatient setting without potent medications that necessitate intensive patient monitoring, pose risks for side effects and add to treatment costs.

A high-efficiency microwave thermoablation system for the treatment of benign prostatic hyperplasia: results of a randomized, sham-controlled, prospective, double-blind, multicenter clinical trial

OBJECTIVES

To determine the effectiveness, safety, and impact on patient quality of life (QOL) of a novel transurethral microwave thermoablation system for the treatment of benign prostatic hyperplasia (BPH).

METHODS

A total of 169 patients with BPH were randomized to undergo a 1-hour microwave (n = 125) or sham (n = 44) procedure using the Urologix Targis thermoablation system on an outpatient basis, without general or regional anesthesia. Symptoms, flow rates, and QOL scores were determined before the study procedure and periodically thereafter up to 6 months.

RESULTS

Mean American Urological Association (AUA) score in the microwave group diminished 50% (P <0.0005) by the 6-month evaluation (10.5, 95% confidence interval [CI] 9.2 to 11.8) compared with baseline values (20.8, 95% CI 19.8 to 21.9). The sham group also exhibited lower postprocedural AUA scores; however, the magnitude of the postprocedural decline in AUA score in the microwave group was significantly greater (P <0.01) than that in the sham group. Half the microwave group had an AUA score of less than 9 by 6 months, and the decrease in symptoms was similar among patients with initially moderate versus initially severe symptoms. Mean peak urinary flow rate (Qmax) in the microwave group increased 51% (P <0.0005) by 6 months to 11.8 mL/s (95% CI 10.7 to 13.0) versus a pretreatment value of 7.8 mL/s (95% CI 7.4 to 8.2). The magnitude of the postprocedural increase in Qmax was significantly greater in the microwave than the sham group (P <0.05). In nearly half the microwave group (47%), Qmax increased 50% or more by 6 months compared with 24% of the sham group. Microwave treatment resulted in a significantly greater (P <0.05) positive impact on patient QOL than did the sham procedure. By 6 months, the QOL score in microwave-treated patients (2.2, 95% CI 1.9 to 2.4) averaged 48% lower (P <0.0005) than that at baseline (4.2, 95% CI 4.0 to 4.4). Significantly greater durability of treatment effects was also evident with microwave than with sham treatment, as judged by the higher proportion of microwave-treated patients (98.4%) requiring no further treatment during the 6-month study period versus 83.3% of sham control patients (P <0.0005). Microwave treatment was well tolerated, and complications were generally minor, readily manageable, and transitory.

CONCLUSIONS

The microwave thermoablation system proved to be an effective and safe treatment modality for BPH, with a positive impact on patient QOL.

Detailed interstitial temperature mapping during treatment with a novel transurethral microwave thermoablation system in patients with benign prostatic hyperplasia

PURPOSE

To delineate in detail the temperature changes in the prostate gland and adjacent structures during treatment with a newly designed microwave thermoablation system in patients with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Microwave thermoablation treatment was administered to 22 BPH patients at two centers in the U.S. and Argentina using the Urologix Targis targeted transurethral thermoablation system. Continuous temperature measurements were made with widely spatially dispersed fiber optic thermosensors at 11 to 24 prostatic sites in each patient using a recently described accurate stereotactic method. Urethral and rectal temperatures were also measured.

RESULTS

Treatment using the microwave thermoablation system resulted in marked elevation of intraprostatic temperatures to as high as 80C in some patients with little or no elevation of urethral or rectal temperatures. Average temperature increased with radial distance from the urethra to a peak at 5 to 7 mm. and declined exponentially at greater distances. Higher maximum intraprostatic temperatures in individual patients were associated with a larger zone, up to 24.0 mm. in radius, of prostatic tissue exposed to thermoablative temperatures of 45C and higher. Along the longitudinal axis of the microwave treatment catheter, thermoablative temperatures were confined to a zone of 11.5 mm. from the microwave antenna midpoint apically and 11.3 mm. basally, that is, a range shorter than the length of the treatment catheter's microwave antenna (2.8 to 3.5 cm.). The mean temperature in the posterior sector of the prostate gland during treatment (43.6C; 95% CI, 41.1 to 46.1C) was significantly lower (p < 0.05) by 6.7C than that in the anterolateral prostate (50.3C; 95% CI, 48.3 to 52.3C), as a consequence of the preferential heating design of the treatment catheter. Intraprostatic mean temperature during treatment, as measured at all thermosensor sites without respect to spatial location, was 47.1C (95% CI, 44.2 to 50.0C), a value significantly higher (p < 0.05) than that measured in the urethra (39.6C; 95% CI, 36.6 to 42.6C) or rectum (37.7C; 95% CI, 36.7 to 38.7C). There was a strong correlation between the temporal pattern of fluctuation in urethral temperature and that of prostate temperature (r = 0.83; p < 0.001) during treatment.

CONCLUSIONS

Treatment with the microwave thermoablation system fulfilled the requirements for an effective and safe microwave-based BPH treatment modality by exposing obstructive tissue to high temperatures without endangering vulnerable adjacent tissues.

A novel transurethral microwave thermal ablation system to treat benign prostatic hyperplasia: results of a prospective multicenter clinical trial

PURPOSE

We evaluated the efficacy, safety and impact on quality of life of a newly designed microwave thermal ablation system in patients with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Microwave thermal ablation was administered to 154 BPH patients at 3 centers in Canada and the United Kingdom during a single 1 to 2-hour office or clinic procedure without general or regional anesthesia and without need for potent medications necessitating intensive patient monitoring. Various measures of symptoms, voiding function and patient quality of life were assessed at baseline, 6 weeks, and-3, 6, 9 and 12 months after treatment.

RESULTS

Mean American Urological Association symptom score 12 months after treatment (8.8, 95% confidence interval 7.7 to 10.0) was significantly lower (p < 0.05) by 56% than that at baseline (20.1, 95% confidence interval 19.1 to 21.0). The incidence of mild symptoms increased from 0 to 57%, while that of severe symptoms decreased from 49 to 8%. There was a significant increase (p < 0.05) in peak flow rate of 45% from 9.3 ml. per second (95% confidence interval 8.8 to 9.7) at baseline to 13.4 ml. per second (95% confidence interval 12.5 to 14.4) at 12 months. Similar symptomatic and urodynamic improvements occurred in all prostate volume categories. Convalescence was rapid after treatment with little or no need for home bed rest or restriction of usual activities. Patients expressed a high level of satisfaction with treatment and found the prostate symptoms to be significantly more tolerable. Adverse events were infrequent, transient and readily managed.

CONCLUSIONS

Microwave thermal ablation proved to be safe and effective for treatment of BPH with a significant positive impact on patient quality of life.

Transurethral microwave thermotherapy for management of benign prostatic hyperplasia: one-year results with the PRIMUS U + R device

We report on one-year results after transurethral microwave thermotherapy (TUMT) in patients with symptoms due to benign prostatic hyperplasia (BPH). The material consists of 91 cases, treated with the PRIMUS U + R device in a single, one-hour out-patient procedure. The International Prostate Symptom Score (I-PSS), S, fell from baseline 23 (17-27) to 12 (7-18.8), quality of life assessment, L, improved from 4 (3-5) to 2 (1-3) and peak urinary flow increased from 9.6 +/- 0.3 to 11.1 +/- 0.4 (ml/sec) after one year. No changes in postvoiding residuals were observed. Sixty five per cent of the patients were assessed as responders to the treatment. Complications were urinary retention and bacteriuria. Neither enlargement of prostate nor a prominent median lobe, seem to be predictors of subjective outcome. TUMT appears to be a safe and, in the majority of patients, effective measure to relieve symptoms due to BPH.

Current status of thermotherapy of the prostate

PURPOSE

We reviewed the available data on transurethral microwave thermotherapy in the treatment of patients with benign prostatic hyperplasia (BPH). Furthermore we provide a perspective of this minimally invasive treatment modality.

MATERIALS AND METHODS

To our knowledge all previously reported data from clinical trials of transurethral microwave thermotherapy for BPH are reviewed.

RESULTS

Transurethral microwave thermotherapy was designed to apply microwave energy deep within lateral prostatic lobes while simultaneously cooling the urethral mucosa, thus enabling an outpatient based anesthesia-free procedure. Lower energy protocols using the Prostraton device provide significant symptomatic improvement and improvement in maximum flow of approximately 35% over baseline. Similar changes are being documented with other transurethral microwave thermotherapy devices. Higher energy protocols using the Prostatron device result in symptomatic improvement similar to that of lower energy protocols, while improvement in uroflowmetry is much more pronounced. However, the latter effect is achieved at the expense of increased morbidity. Second generation protocols have not yet been documented by users of the other thermotherapy devices.

CONCLUSIONS

Numerous studies unequivocally support the efficacy and safety of transurethral microwave thermotherapy for treatment of symptomatic BPH. Significant improvement in objective and subjective parameters has been realized with transurethral microwave thermotherapy at multiple centers in the United States and Europe.

Transurethral microwave thermotherapy for management of benign prostatic hyperplasia: durability of response

OBJECTIVES

The durability of clinical efficacy of transurethral microwave thermotherapy (TUMT) by Prostatron using a low-energy protocol (maximum power, 50 W) was evaluated on an outpatient basis in patients with symptomatic benign prostatic hyperplasia (BPH).

METHODS

One hundred eighteen patients were followed up for longer than 3 months (13.4 +/- 9.5 months; mean +/- SD). All evaluations were made at baseline and then 3, 6, 12, 24, and 36 months after therapy.

RESULTS

International Prostate Symptom Score (IPSS) significantly decreased from 18.2 to 10.6 at 6 months (P < 0.01), representing a mean improvement of 41% under the baseline. Peak flow rate increased from the baseline of 8.3 mL/s to 10.3 mL/s at 6 months (P < 0.01). The improvement in terms of mean values of both parameters was sustained up to 24 months. Six of 44 patients (14%) who were followed up for 31 months on average required transurethral resection of the prostate for recurring obstructive symptoms and 10 additional patients (23%) had to be treated with various drug regimens. When the clinical outcome was evaluated in terms of improvement from the baseline according to a response criteria, disease-free rates for IPSS (more than 25% improvement from the baseline) were 76% at 12 months, 77% at 24 months, and 61% at 36 months. Disease-free rate for peak flow rate (more than 2.5 mL/s from the baseline) was sustained in 44% by 12 months and in 48% by 24 months. The overall outcome of the treatment was assessed by adding scores based on both subjective and objective efficacy criteria. At 6 months, 67% of the patients were responders, and 15 of 21 (71%) remained as responders at 24 months. Patients who had estimated prostate volume smaller than 30 cc showed more marked improvement in peak flow rate (P < 0.02), and those with baseline IPSS of 20 or more showed greater reduction of IPSS (P < 0.05) at 24 months compared with each counterpart.

CONCLUSIONS

After TUMT with a low-energy protocol, satisfactory results were obtained and the improvement seems to last at least for 24 months. This low-energy protocol may be most beneficial in patients with relatively small size of the prostate.