Transurethral Vaporization of the Prostate

Whereas TURP removes tissue by resection of prostatic tissue and causes hemostasis by fulguration, transurethral vaporization of the prostate (TUVP) is brought about by combining the concepts of vaporization and desiccation. Desiccation is the drawing out of water from tissue, by drying out, rather than vaporizing the cells. This concept was introduced by Mebust and coworkers (1972, 1977) using a transurethral probe with direct-vision capabilities to heat and desiccate the prostate. TUVP was first described by Kaplan and Te (1995a, 1995b).

Mechanism of Action

With TUVP, two electrosurgical effects are combined: vaporization and desiccation. Vaporization steams tissue away using high heat, and coagulation uses lower heat to dry out tissue. Other factors are also involved that modify the delivery of electrical energy. These include the voltage production by the generator, the current density of the surface area of contact of the electrode, and the electrical resistance of the tissue being treated (Kaplan et al, 1998).

In the case of TUVP the electrode’s leading edge is the point at which maximal efficiency for vaporization occurs, as well as that of current density delivery. At the point of the trailing edge of the electrode there is a decrease in the delivery of current, lowering the power and permitting tissue desiccation to occur. Therefore vaporization occurs at the leading edge and desiccation occurs at the trailing edge (Kaplan et al, 1998).

The power of the generator determines whether vaporization occurs at the leading edge of the electrode. The electricity that is transmitted to the cell is converted to heat, resulting in the cell exploding or drying out. This is dependent on the conduction of electricity by the cell or the tissue resistance encountered by the current. In simple terms, the well-hydrated cell conducts electricity well, whereas the drier the tissue, the greater the electrical resistance. Clearly, a higher power is required to overcome this resistance, which may lead to poor vaporization if the power cannot be varied.

The type of generator used is also important in deciding the effectiveness of the vaporization. Older machines do not have a method of modulating delivery of power to the tissues depending on the degree of resistance encountered. Usually, therefore, the power is switched high to overcome this problem. The balance then is in some cases controlled by the limitation of the amount of current required to maintain a constant power. This safety feature prevents the delivery of an ever-increasing voltage that would compensate for the increase in resistance associated with the drying out of tissue that would occur with vaporization. This could potentially lead to unwanted damage both to the local tissues and to other areas such as the urethra. For this reason, modern generators specifically designed for TUVP can vary the delivery of power by reading tissue resistance. In addition, the safety feature described earlier whereby power can be limited is set at a higher level, thus making TUVP more efficient.

For TUVP, the cutting current power should be set to a maximum of 75% higher power than for a standard TURP, but the power used need not always be as high as this. In fact, it has been estimated that a minimal power delivery of 150 W is required for TUVP (van Swol et al, 1999).

Electrode Design

The rollerball, which is traditionally used for fulgurating the base of superficial bladder tumors, can be used for TUVP. However, it should not be used for prostates that are particularly large. In the study by Juma (1996), it was most effective in patients with glands whose mean volume as estimated by TRUS was 31.9 mL. The effectiveness in larger glands is probably limited by the shape of the rollerball, where the most satisfactory vaporization takes place at the middle part of the leading edge, assuming an equal distribution of contact pressure.

A grooved rollerbar has been widely used and consists of a bar that is 3 mm wide and 3 mm in diameter, which is composed of nickel-silver and insulated with Teflon (Vapor Trode, Circon-ACMI, Stamford, CT). The design is superior to the standard rollerball because the grooved design increases the number of leading edges at which electrovaporization takes place, and this allows increased efficiency of vaporization to a wide contact area and thus to a larger volume of tissue (Narayan et al, 1996; Reis et al, 1999). A similar grooved electrode has also been produced (Richard Wolf, Germany), known as the EVAP.

New second-generation vaporizing electrodes have been manufactured and evaluated. They have the aim of both vaporizing and resecting prostatic tissue simultaneously and have been termed vaporizing loops by some. The technique has been given several possible names in the literature, all amounting to the same thing: transurethral vaporization-resection of the prostate (TUVRP), thick-loop TURP, vapor-cut electrovaporization-resection (Cabelin et al, 2000).

Some examples of these are testament to the inventiveness of many of the instrument companies in relation to design. The Vapor Tome (Circon-ACMI, Stamford, CT) is a thick loop with grooves, giving a thin leading edge for vaporization and a thick trailing edge for desiccation. The Wedge (Microvasive, Natick, MA) is a smooth loop with the same edge configuration, made of stainless steel, tungsten, and chromium. The Wing EVAP (Richard Wolf, Germany) is a semicircular gold-plated wide loop that is wider and thicker than the standard TURP loop (Cabelin et al, 2000). Other modifications are under investigation, in which not only new electrodes but also specific electrosurgical generators are being developed, the aim of which is to reduce side effects while maintaining efficacy and also decreasing the potential risks of high-voltage power to the tissues surrounding the prostate.

Clinical Experience with Electrovaporization

The first report of TUVP was from Kaplan and Te (1995a), using the Vapor Trode. They reported on 25 men with moderate LUTS with a mean prostatic size of 57.6 mL. There was an improvement in AUASI from 17.8 to 4.2 at 3 months and in PFR from 7.4 to 17.3 mL/sec at the same time. The most encouraging findings were that all of the patients had their catheters removed within 24 hours (mean, 14.6), but by 3 months 1 patient had developed a distal urethral stricture. In the study by Juma (1996) using the standard rollerball in a study of 20 patients for 3 months, the results were similar, although 1 patient developed a bladder neck stenosis and 1 required repeated TURP.

Other pilot studies also suggested that a comparative trial would be appropriate because of the efficacy and safety that had been demonstrated. Galluci and his colleagues (1996) treated 35 patients with the Vapor Trode and found that improvements at 28 days were as encouraging as those at 3 months in other studies (PFR, 9.8 to 20.74 mL/sec; AUASI score, 18.2 to 10.4), but of note was that the standard deviation of the mean in both cases was very wide. Stewart and colleagues (1995) with the same electrode treated 34 patients, 20 of whom were in urinary retention; 33 of 34 were voiding satisfactorily. In a study of 22 patients subjected to pressure-flow analysis at 6 months, the mean Pdet at PFR decreased from 108 to 39 cm H₂O (Okada et al, 1998). Similar results related to relief of obstruction in 91 patients were reported by Matos Ferreira and Varregoso (1997).

Comparative Studies

All of the pilot studies were short term, none longer than 6 months, but comparative studies were indicated, and several of these compare TUVP with TURP. Patel and colleagues (2000) have carefully reviewed five of these in which different types of electrode were used (Galluci et al, 1996; Patel et al, 1997; Shokeir et al, 1997; Hammadeh et al, 1998; McAllister et al, 1998). A total of 270 patients had TURP, whereas 262 patients had TUVP. A comparison of complications shows that postoperative irritative symptoms, urinary infection, 1-year reoperation rate, and urethral stricture were the same in both groups. However, catheter duration postoperatively, hematuria, transfusion rate, and retrograde ejaculation were lower in the TUVP group, as was hospital stay. Operating time, postoperative urinary retention, impotence, and urinary incontinence were higher in the TUVP group. Again, these were all short-term studies, with follow-up to a maximum of 1 year. In some cases, the numbers of patients who had actually reached 1-year follow-up were not stated. In addition, the range on either side of the mean was quite wide. All of the studies showed significant improvements in symptom score and PFR, which were maintained to the time of maximal follow-up in the study reported.

In most studies the size of the prostate gland operated on was 60 mL or less as measured by TRUS. The follow-up period for these studies needs to be much longer than 1 year so that the comment “TUVP is an acceptable alternative to TURP” can be sustained. In addition, the complication rates in some studies are rather high; for example, the study by De Sautel and colleagues (1998) shows that in a relatively small number of cases TUVP is as effective as TURP in relieving urodynamically proven outflow obstruction, but the overall complication rate for TUVP was 17.5%.

There has been a somewhat longer randomized trial comparing TUVP with TURP (McAllister et al, 2003). In this study, 235 patients with symptomatic BPH were randomly assigned to the two treatment options and it was a multicenter trial from four study centers in the United Kingdom. Forty-five of the 235 presented with acute urinary retention, and for the remainder a reduction in IPSS of 5 or more points was defined as success; statistically, and using this definition of success, 220 patients were required in the study to be able to detect a 15% difference in treatment outcome with 80% power at the 5% level. The mean reduction in prostate volume was the same in both groups, as were the operating time, hospital stay, and the improvement in symptom score, PFR, and postvoid residual volume. The transfusion rate was higher in the TURP group. At 6 months, 9% of the TURP group had become impotent, compared with 17% in the TUVP group, but this difference was not statistically significant.

A meta-analysis was performed comparing the efficacy and safety of TUVP and TURP for symptomatic BOO secondary to BPH. From a total of 25 randomized controlled trials, 20 met the predefined inclusion criteria and were subjected to a formal analysis. A total of 1489 patients were randomly assigned to TUVP (708) or TURP (781). There was a considerable variation in the follow-up, but the median was 12 months. The meta-analysis found a considerable limitation to most of the studies, particularly pertaining to the justification of sample size, randomization, the procedure for concealing treatment allocation, and the appropriate handling of study withdrawals to maintain the principle of intention-to-treat analysis. None of the studies estimated the sample size before starting the study as part of their calculation of statistical power, and only two described how the random allocation sequence was generated. There was also a considerable variation in the method of reporting the outcomes of the individual studies. Once again, this meta-analysis, as others related to other minimally invasive treatments have shown, demonstrates a poor database for drawing meaningful conclusions. However, it did suggest that TURP and TUVP provide comparable improvements in AUASI score and PFR for up to 1 year of follow-up (Poulakis et al, 2004).

Vaporization-Resection

A number of relatively short-term pilot studies using the Wing, Wedge, and Vapor Cut electrodes have been published and have been summarized by Cabelin and colleagues (2000). They have shown that the efficacy and complication rates are the same as with the standard Vapor Trode. The number of patients treated varied from 31 to 91, and the size of the gland ranged from 39 to 59.6 mL. The operating time was long (49.3 to 56.7 minutes), but the AUASI score decreased from 24.3 to 4.1 with the Wing and from 19.0 to 7.2 with the Vapor Cut. The PFR improved from 5.2 and 8.9 to 16.0 and 18.4 mL/sec, respectively (Perlmutter and Schulsinger, 1998; Küpeli et al, 1999; Perlmutter and Vallencien, 1999; Talic, 1999).

A comparative study between TUVRP and TURP has been reported by Talic and coworkers (2000). The Wing resection electrode was used in the TUVRP group. All patients were observed for about 9 months, with a range of 6 to 15 months. At 6 months the TUVRP group had improvements in AUASI score (24.9 to 4 ± 3.4) and PFR (7.5 to 19 ± 6.5 mL/sec); the TURP group had comparable improvements in symptom score (20.1 to 5.6 ± 3.1) and PFR (9.1 to 15.2 ± 10 mL/sec). Of particular note is the very wide range on either side of the mean values.

Summary

TUVP and TUVRP are technologic innovations based on an idea that has been present for some years. Modifications are being made in the equipment that will make this even safer and that will prevent some of the potential problems associated with the delivery of high power to tissues. Efficacy appears similar to that of TURP, but the studies are short-term evaluations and the glands operated on are relatively small. The short-term complication profile appears to be better than with TURP, but further studies are required to prove this because there is a certain variability in the rate of occurrence of some of them. In general, although the catheterization time is shorter than with TURP, the operating time is longer. Before this can be accepted as a technique that will replace TURP, long-term multicenter randomized trials are required. However, the technologic improvements and the consistently similar short-term improvements in AUASI score and PFR are encouraging.

Transurethral Incision of the Prostate

If a poll were to be taken among urologists as to how many would favor a transurethral incision of the prostate (TUIP) as treatment for symptomatic BPH, it is likely that the number would be very small. However, TUIP has been available since the 19th century. Edwards and colleagues (1985) credit Bottini with describing the technique in 1887, but Hedlund and Ek (1985) credit Guthrie in 1834. Guthrie’s technique was to disrupt the bladder neck, whereas Bottini used diathermy to divide it. However, in 1973, Orandi published the first significant series on TUIP. The procedure seemed to be most useful in those who had a small prostate and who had obstructive bladder outflow symptoms. Classically, the patient was a younger man when compared with those having TURP (Orandi, 1973).

Technique

The surgical technique is relatively simple. With a Collings knife, an incision is made at the 5- and 7-o’clock positions or on one side of the midline only. It starts just distal to the ureteral orifice and ends just proximal to the verumontanum (Fig. 93–16). The incision depth should be to the point at which fine filaments of the external capsule are seen. Care must be taken not to incise too deeply because extravasation of irrigation fluid or rectal injury may occur. With completion of the incisions and with the scope in the more distal urethra there should be no visible obstruction to the bladder outflow.

Figure 93–16 Transurethral incision of the prostate. The incision is started at the ureteral orifice and carried through the bladder neck up to the verumontanum. This procedure is done bilaterally.

(From Mebust WK. A review of TURP complications and the National Cooperative Study, lesson 24, volume VIII. 1989. p. 189–90.)

Complications

The advantage of TUIP is that it is quick, technically easier, and associated with less morbidity and a decrease in retrograde ejaculation compared with TURP. The incidence of retrograde ejaculation after TURP ranges from 50% to 95%; but after TUIP it has been reported as occurring in 0% to 37% of cases. Turner-Warwick (1979) noted that with one incision the incidence of retrograde ejaculation was less than 5% but with two incisions it was 15%. Hedlund and Ek (1985) reported no difference between this incidence with one and with two incisions.

Clinical Efficacy

The procedure has been assessed by some open studies using strict urodynamic criteria for evaluation. Edwards and Powell (1982) found a significant reduction in voiding pressure after TUIP. Kelly and colleagues (1989) used pressure-flow curves and showed a significant fall in voiding pressure, with shift of the Pdet at PFR from the obstructive to the equivocal range on the Abrams-Griffiths nomogram. They found it to be less effective than TURP in relieving obstruction. Katz and colleagues (1990) noted a satisfaction rating of up to 94% with a significant improvement in symptoms and PFR after TUIP.

Sirls and colleagues (1993) reviewed 41 men (mean age, 63.4 years) for a mean follow-up of 53 months. The Boyarsky symptom score decreased from 12.5 to 6.9, and the PFR improved from 10.3 to 15.3 mL/sec. The postvoid residual urine volume decreased from 179.8 to 99.4. The Pdet at PFR decreased from 84.5 to 44.5 cm H₂O, all of which indicated an excellent response to TUIP, particularly if the prostate gland weighed 30 g or less.

In the largest series, Orandi (1985) reported on 646 patients whom he had observed from 3 months to 15 years, finding a reoperation rate of 9.6%.

Comparative Studies

Orandi (1973), in a prospective study over a 2-year period of 132 patients managed with TURP or TUIP, found that the results and complications did favor TUIP but there was no statistically significant difference between the two treatments. The only apparent difference was the higher incidence of bladder neck contraction after TURP.

Miller and associates (1992) reported on 108 patients who underwent a bladder neck incision and compared them with a similar group undergoing TURP. They believed that bladder neck incision was better than TURP in terms of a shorter operative time and shorter duration of catheterization. No other perioperative differences were found. For the 10-year follow-up there was no difference in reoperation rates between the two groups, with an equally high approval by patients after both procedures. In another comparative study, Soonawalla and Pardanini (1992) found that the PFR increased from 8 to 19 mL/sec after TUIP and from 8 to 21 mL/sec after TURP.

Dorflinger and coworkers (1992) randomly assigned 60 patients to either TURP or TUIP. They found that both operations significantly improved AUASI score and PFR, but the improvement in PFR was better for the TURP group. Neither operation caused any significant change in sexual activity or erectile function postoperatively. Retrograde ejaculation was a more common occurrence in patients treated by TURP. Riehmann and colleagues (1995) randomly assigned 56 patients to TURP and 61 to TUIP, and there was a mean follow-up of 34 months. Differences in PFR improvement were significant statistically at 3 months and 24 months only and not at any other time. Retrograde ejaculation was twice as common in the TURP group. Reoperation was required in slightly more patients in the TUIP group, but the difference was not statistically significant. The AHCPR BPH Guideline Panel (McConnell et al, 1994) performed a meta-analysis of the various studies, and the results are noted in Table 93–5. There is a slightly better chance of improvement of symptoms of patients treated by TURP, as there is in the degree of that improvement.

Table 93–5 Treatment Outcomes Balance Sheet

OUTCOME	TUIP	TURP
Chance of symptom improvement	78%-83% (80)	75%-96% (88)
Degree of symptom improvement	73%	85%
Morbidity (20% significant)	2.2%-33% (14)	5.2%-30.7% (16)
Mortality (30-90 days)	0.2%-1.5%	0.53%-3.31%
Incontinence (total)	0.061%-1.1%	0.68%-1.4%
Operative treatment for surgical complications	1.34%-2.65%	0.68%-10%
Impotence	3.9%-24.5%	3.3%-34.8%
Retrograde ejaculation	6%-55%	25%-99%

TUIP, transurethral incision of the prostate; TURP, transurethral resection of the prostate.

From Barry MJ, Fowler FJ Jr, O’Leary MP, et al. The American Urological Association’s symptom index for benign prostatic hyperplasia. J Urol 1992;148:1549–57.

Summary

TUIP is effective in treating patients with LUTS caused by BOO. It has been shown to have an important role in the management of younger patients, especially if the prostate is smaller than 30 g. The efficacy is comparable in such patients with TURP, and the results are maintained in the long term. The technique is simple, and the morbidity is low.

Other Technologies

There are some other approaches that have not been previously mentioned in this chapter but they are included only to complete the picture. There is no significant evidence available to support any of these as having a future in the treatment of symptomatic BPH. The literature mainly consists of open studies, which in many cases would correspond to phase 1 trials or very small phase 2 trials.

Water-Induced Thermotherapy

Water-induced thermotherapy is another treatment introduced to treat LUTS and to reduce BOO secondary to BPH. An early article (Corica et al, 2000) assessed its effect on prostatic tissue, using it in both benign and malignant prostates, in 27 patients. The patients were awake, with local anesthetic gel inserted urethrally. The discomfort experienced by patients was recorded as mild. Pathologic examination of the removed prostate consistently showed periurethral hemorrhagic necrosis extending up to 11 mm from the urethra, focal or extensive urothelial denudation, and mild inflammation.

The same group of authors subsequently developed a novel rapid high-temperature, liquid-filled, flexible balloon thermotherapy system (Corica et al, 2003). The same anesthesia as previously was used in 17 patients, and a full histologic study was performed. Again, consistent findings were recorded, including periurethral hemorrhagic necrosis, extensive denudation, and varying degrees of inflammation. The mean depth of necrosis was 0.9 cm, involving a mean of 16% of the prostatic adenoma. In the prostates examined later, the necrotic tissue had been replaced by scar tissue (fibrosis and hyalinization) with a mean depth of 0.13 cm.

In a small open study, two slightly different temperatures were used in two groups of patients (Breda and Isgro, 2002). Because of the small numbers the results are somewhat difficult in that the temperature did not matter and that previously catheter-dependent patients were able to void with a PFR of 10.7 to 11.5 mL/sec in 73% to 88% of patients.

There has been a prospective multicenter trial performed involving 125 patients (Muschter et al, 2000). Improvement was noted at 3 months, extending to 12 months. The IPSS at 12 months had improved by a median of 12.5 symptom units and the PFR improved by 6.4 mL/sec over baseline. This was not a comparative study. Side effects were minimal. The authors concluded that the treatment held promise as a useful and cost-effective option for management of BPH. In a later review of the topic, the failure rate and rate of subsequent TURP were reported as 5.6% after 12 months, 9.6% after 24 months, and 11.2% after 36 months (Muschter, 2003).

Transurethral Ethanol Ablation of the Prostate

This technique has not been subjected to a great deal of in-depth study. It was initially introduced as a transperineal injection, with phenol being the agent injected (Talwar and Pande, 1966; Angell, 1969). There was clear evidence from several early studies that the agent injected leaked extraprostatically, with consequently a relatively high incidence of significant adverse events. The development of a transurethral method of injecting ethanol has been seen as a safer approach (Goya et al, 1999; Ditrolio et al, 2002). A detailed description of the injection technique is to be found in these articles and in the study presented by Plante and colleagues (2003), who also describe the histologic findings observed in the canine prostate. They found a considerable lobular volume of necrosis (mean of 42.6%); and although the findings were not absolutely consistent, they found that the prostate capsule always acted as a relative barrier to ethanol diffusion after transurethral injection.

A European multicenter study has been performed in 115 symptomatic BPH patients using transurethral ethanol ablation of the prostate (Grise et al, 2004), and 94 of these patients were observed for 12 months. An average reduction in prostate volume of 16% was found, with a small adverse event rate and a requirement for TURP in 7% of patients in that time period. Relatively modest improvements in IPSS and PFR were reported, with 98% of patients voiding spontaneously 4 days after treatment.

Rotoresection of the Prostate

This technique has not been widely reported, but early studies, both experimental and clinical, have been published. It has been designed for conventional transurethral application, with an axially adjustable actively rotating crank with a milling-head spiked electrode fitting into a specifically designed working element instead of a loop electrode. It is driven by a micromotor, which transmits rotation to the electrode by an angled drill handle. The first use of this system was reported by Michel and coworkers in 1996. In an experimental porcine model these researchers found a rate of time ablation comparable to that of a standard resection loop (5.5 to 6.0 g/min) and more than twice that of electrovaporization (1.7 to 2.0 g/min). The rate of bleeding was significantly better than for either, and the depth of tissue coagulation was 1.5 mm, compared with 0.4 mm with TURP.

There have been three clinical studies. Michel and coworkers (2003) used the rotoresect system in 84 patients and evaluated them for up to 4 years. They found no change in hemoglobin or serum sodium values. The mean duration of catheterization was 1.4 days. There was an early significant improvement in IPSS and PFR, which lasted to the 4-year evaluation.

A prospective study was carried out, and results at 12 months (Wadie et al, 2003) and 24 months (Wadie et al, 2005) have been published. In the latter report the results of 23 of the original 24 patients have been evaluable. The AUASI score decreased from 20.5 ± 3.8 to 1.12 ± 1.56, and the PFR rose from 8.7 ± 2.1 to 21.8 ± 8.5 mL/sec, results comparable to those reported earlier. Again, the complication rate was found to be low.

Summary

Since the previous edition of this book there is very little new apart from the explosion of interest in the newer types of laser therapy. Many of the recent papers on thermotherapy describe newer techniques but once again fail to get to the “meat” of the subject, which is to answer the question as to the exact position of thermotherapy in the management of BPH. Even in the case of the laser therapies, the authors do not tell the reader if they consider that they will actually overtake TURP and supplant it in the future. In addition, the standard of trials has not improved greatly, with many still being open label studies with no comparator group; some of the comparative studies have group sizes that do not give the impression of having been powered statistically to show either equivalence or a specifically stated difference. There have been several new meta-analyses or systematic literature reviews, which may help the reader to make a more balanced, evidence-based decision.

There has been much discussion as to which of these therapies is better than TURP. At present, it would seem that TURP is either equivalent to the best of the minimally invasive therapies or better than most in terms of improvement of subjective and objective indices. As was stated in the introduction, however, it is not only the efficacy of the treatment that must be compared with TURP. The adverse event profile, the requirement for intravenous sedation, length of hospitalization, and cost also are all very important.

The vast majority of trials that have been reported compare a treatment with TURP only against efficacy, whereas it would be of benefit to the urologist if trials could view the comparison of the other factors in a prospective way, perhaps even excluding efficacy. This has been done by some authors, but a major multicenter approach would give the best information. In this way, it would be clear which is the best way to treat BPH.

However, the view could be taken that it is not necessary to find a minimally invasive treatment that is better than TURP. For example, none of the drug treatments has even come close to the efficacy of TURP, but they have been demonstrated to be of lasting value in management and have found a very specific place in the treatment armamentarium of BPH. In that case, the questions just posed would need to be answered very carefully.

It might be considered controversial to state that perhaps patients should be allowed to have sequential treatments. It is known that some patients do not respond well to specific minimally invasive treatments, so perhaps they might have a second treatment with the same modality, even a relatively short time after the first. There may be cost implications that would have the hospital managers shaking their heads, but it would certainly lower hospital bed requirements if it proved successful. In the same way, if a treatment proved efficacious for a 3-year period and then the symptoms returned, it is conceivable that a further treatment might return the patient to symptomatic well-being, even if a further full evaluation was required.

What is definitely necessary is that the exact place for each treatment modality should be found. Some may well have a small but well-defined role in the management of BPH, and, in the case of others, this role may be larger. One of the problems with extracorporeal shockwave lithotripsy was that it took a long time to find exactly how it should be used to treat, for example, staghorn renal calculi; no comparative trial was performed. In the same way, TURP was introduced without a comparative trial; and although it is recognized now as the gold standard, it took several decades before this happened. Minimally invasive treatments are in most cases pitted against TURP, but with many of them this has been a wasted exercise because in the preliminary open studies they could have clearly been seen not to be as efficacious. Commercial necessity requires comparison against a recognized treatment, but often this is not in the patients’ best interests. It may be that the treatment has a lesser, but equally important, role to play.

At the International Consultation on BPH, held in July 2000, the committee that discussed “International Therapy for Benign Prostatic Hyperplasia” prepared a report (Debruyne et al, 2001). In it was outlined final recommendations on the use of such treatments, which were defined as acceptable, acceptable with restriction, investigational, or unacceptable. This decision was based on several meetings between the members of the panel and is rather a suggestion than an instruction to urologists.

The panel found that a number of treatments for BPH were unacceptable: balloon dilatation, hyperthermia, and high-intensity focused ultrasonography. It is widely accepted that this is so, and these treatments have not been dealt with in this discussion because it is unlikely that they will have a role in the future in their present form. Prostatic stents are deemed acceptable with restriction, which once again is not controversial because that restriction has been clearly described in the large number of original and review articles related to them.

Rather more interesting is the list of treatments described as being acceptable, presumably without restriction in the minds of the panel: TUMT, transurethral needle ablation, interstitial laser coagulation, laser-vaporization, and transurethral electrovaporization (naturally, TURP and open prostatectomy are also included). It may be that these newer treatments are acceptable, but it is absolutely necessary to define in what way and to remember that, in most of these treatments, the results are short term. In some cases, they may be considered as possible replacements for TURP, but, in that case, a large amount of further information is required related to the points previously discussed and to long-term efficacy. In the case of those being considered as alternative treatments for BPH not necessarily as good as TURP, their exact role needs to be defined.

It is very likely that some day TURP will be replaced as the ideal interventional treatment for BPH. It took a considerable amount of time for TURP to achieve its exalted position, but it could happen soon that some other treatment will occupy that position.

Key Points

• Intraprostatic stents are confined to alternative therapy for BPH for patients unfit for TURP.

• Transurethral needle ablation has been modified several times and has a significant beneficial effect on PFR and IPSS. Not enough long-term studies are available.

• The literature base for TUMT is inconsistent, and it is not possible to draw conclusions on long-term efficacy. It also improves PFR and IPSS.

• The holmium laser and the high-power PVP laser are the most popular instruments in this technology section and are efficacious in improving PFR and IPSS, probably in a way that is comparable to TURP. Long-term studies are required.

• TUVP and TUIP are also effective, particularly for small prostates, but have not overtaken TURP as the chosen method to treat obstructive BPH.

• In well-trained hands, TURP is a safe and effective way of treating BPH, with an acceptable side effect profile.

• Other means of prostatic resection, such as rotoresection of the prostate, are under evaluation, without long-term multicenter trials as yet. The efficacy of water-induced thermotherapy and ethanol injection of the prostate remains unproved.