Prostatic Hyperplasia: Evolution of Treatment Julie M Riley MD

Ancient Years Prostate was originally used in 300 BC but “forgotten” until 1550 1649: Jean Roilan suggested that an enlarged prostate caused retention Managed with catheters and sounds

Punch Techniques 1575: Pare used a punch tip to pass through and clip the prostate 1756 Lafaye passed a lance-shaped stylet through the median lobe Patient lived for 10 years Others tried with fatal result 1761:Morgagnidescribed BPH with associated bladder findings on autopsy Lafaye patient at autopsy had false passage

Early Days 1815: Syng used a metal catheter with a balloon on the end to dilate the prostate Most therapies were ineffective and painful. Many proved fatal Held pressure for as long as the patient could tolerate, usually ~15 minutes

Adenectomy Started in conjunction with perineal lithotomy First complete adenectomy was in 1891 With anesthesia and antiseptic techniques, suprapubic approach was favored 1911: Squier performed first suprapubic prostatectomy as performed today

Transurethral Surgery 1830: Guthrie used a knife to incise the bladder neck 1873: electrocautery was used to burn after incising 1897: paired with cystoscope, allowed for visual control 1908: Bugbee and others used monopolar current to detroy prostate tissue 1926 Collings used current to cut tissue and the resectoscope was invented by Stern Davis improved monopolar energy with two currents, one to cut, the other to coagulate

Early Days TURP remained the gold standard of BPH but problems continued Bloody Requires cessation of anticoagulation TURP syndrome hospitalization

Along came the Laser

Laser Treatments TULIP: requires ultrasound rather than direct visualization Not as effective as traditional TURP Replaced by newer technology

Laser Fibers Nd:YAG: wavelength of 1064 nm Penetrates deeply, poorly absorbed by water or blood Tissue becomes white and sloughs after treatment KTP (Greenlight): wavelength of 532 nm Half the depth of penetration compared with ND:YAG which causes higher energy per tissue volume Holmium: 2100 nm Series of rapid pulses Vaporizes the tissue water, worse hemostatic properties Very little tissue penetration Diode: 980 nm Absorbs both water and blood Thulium: 2097 nm Contiuous wave, allows smoother cutting Neodynium: Yittrium-Aluminum-garnet laser Potassium-titanyl-phosphate laser

Laser Fibers

Nd:YAG laser First widely used laser for prostate Initially used for vaporization Significant prolonged LUTS as tissue sloughed Developed contact tip which allowed for ablation Not suitable for >40g prostates Also used for interstitial laser coagulation High retreatment rates Similar to vaporization, LUTS and retention common postoperatively 30% had LUTS or retention following vaporization at 3 months

KTP laser Originally used with Nd:YAG as hybrid procedure KTP used to incise bladder neck Now used independently as green light laser Have 120 W laser Performed in noncontact fashion Allows for immediate relief of symptoms even in very large prostates With the higher power KTP lasers, ability to coagulate has decreased Hybrid procedure designed to reduce the rate ofpostop retention and LUTS

Diode Laser Allows for vaporization like 120W KTP laser but better hemostasis like 80W KTP Higher rate of irritative symptoms and epididymitis

Ho:YAG Laser Ideal laser for vaporization as small absorption depth and ability to coagulate blood vessels HoLAP was bloodless with minimal char but too slow for large prostates HoLRP: used end firing laser to remove chips Slow and technically difficult HoLEP: simulates open approach Size no longer an issue

Thulium Laser Used similarly to Holmium laser Better vaporization ability leads to smooth incisions Better visualization of planes

Refinements to the TURP

Complications Mortality rate significantly declined from 5% in 1976 to 0.2% in 1989 More contemporary studies find mortality rate similar to those on observation of BPH Complications were as high as 18% in 1989 but more recently describes as 9% Included retention (4%), perforation of capsule (2%), transfusion (1%) Best longterm outcomes in men with bothersome symptoms at baseline

TURP Refinements Continuing morbidity lead to development of bipolar TURP (Gyrus) Allows use of saline essentially eliminating TUR syndrome Early studies demonstrate earlier discharge and earlier removal of catheter Decreased clot retention Comes in loop and button

Other Technologies

Transurethral Needle Ablation Low level radiofrequency energy Increase temperature >60C to induce necrosis Can be down under local anesthesia Creates 1 cm necrotic lesions without damage to surrounding tissue Delivery via catheter inserted under direct vision Position needles using TRUS Teflon shield on the catheter to protect the urethra 2 needles can treat ~20 grams 5 minutes of treatment per lesion

TUNA Long term results are scarce but still promising Not quite as good as TURP but see 50% improvement in IPSS and flow rate Complication rates are low Retention, irritative voiding symptoms, bleeding, infection, stricture Best for large lateral lobes, <60 grams Retention 40% at 24 hours Irritative symptoms last 1-7 days

TUNA

Transurethral Microwave Therapy Heat prostate tissue while simultaneously cooling urethral mucosa Causes heat induced necrosis, sympathetic nerve degeneration and apoptosis Not as effective as TURP but less complications Improved results over sham surgery except in 1 study Long term data is starting to be accrued

TUMT

What’s Next Lasers continue to evolve Novel techniques Erbium is coming Need more portable, cheaper fibers Improve irritative symptoms following surgery Novel techniques Need a method that can be offered in the office with minimal anesthesia Needs to be portable and cheap, accessible Improve retention rates to avoid post op catheters Erbium is more expensive and delivery method may be toxic