Reasons to overthrow TURP: bring on Aquablation.

PURPOSE: In this review, we will discuss the state of the literature regarding Aquablation, its limitations, and opportunities for its application in the treatment of benign prostatic enlargement (BPE). METHODS: A comprehensive review of original research on Aquablation was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, greenlight photoselective vaporization of the prostate, and simple prostatectomy were reviewed for discussion. RESULTS: For small-medium prostates (30-80 mL), Aquablation's main advantages include better ejaculatory function and similar functional outcomes compared to TURP. For large prostates (80-150 mL), Aquablation demonstrates shorter operative time and superior ejaculatory function when compared to simple prostatectomy, HoLEP, and Greenlight PVP. In addition, Aquablation displays shorter hospital stays than simple prostatectomy. The integration of software programming and semi-automatic technology increases the reproducibility of the procedure and helps standardize overall outcomes, while also accelerating the learning curve. Its ability to preserve antegrade ejaculation makes Aquablation a very compelling option for sexually active patients. However cost and postoperative bleeding risks remain a concern. CONCLUSION: The current evidence suggests that Aquablation is a safe and effective alternative for BPE for small to large prostates. Further prospective clinical trials, with comparisons to other BPE modalities, and data from longer follow-up periods are still required.

A Digital Controlled Pulse Generator for a Possible Tumor Therapy Combining Irreversible Electroporation With Nanosecond Pulse Stimulation.

The irreversible electroporation with microsecond electric pulses is a new ablation technique adopted in the tumor therapy worldwide. On the other hand, the nsPEF (nanosecond pulsed electric field) has been proved to provide a means to induce immunogenic cell death and elicits antitumor immunity, which is under intensive in-vitro and in-vivo studies and in clinical trials. Normally, one needs two different types of electric pulse generators for producing the pulses in the ranges of nanosecond and microsecond, respectively. In order to realize these two types of tumor treatments in complementary and optimize electrical pulse parameters, we have developed a compact high-voltage pulse generator with a wide pulse width tuning range, based on a capacitor discharging configuration digitally controlled by a silicon carbide MOSFET switching array through a pair of optic-coupler drivers. The developed digital pulse generator is capable of adjusting: pulse width over 100-100 µs, voltage over 0-2 kV and repetition rate up to 1.2 kHz. The pulse generator is designed in simulation, implemented and verified in experiments. The pulse generator is shown to deliver a complementary treatment on Murine melanoma B16 cell lines, i.e., triggering the cell early apoptosis under the 300 ns pulse stimulation while a complete killing under the 100 ns pulses. The pulse generator is further demonstrated to induce antitumor immunity in a preliminary in vivo study on the mice model.

Surgical recurrence of solitary fibrous tumor of the pleura treated with microwave (MW) thermoablation: A case report.

Solitary fibrous tumor (SFT) of the pleura is a rare neoplasm which is challenging for clinicians to treat and radiologists to diagnose. Herein, we report a case of recurrence of SFT of the pleura in a 77-year-old patient which was diagnosed and surgically treated on the first occasion in 2005. The patient had a recurrence in 2016 which was treated and then six months later, he again experienced chest pain and a further local recurrence was found. Taking into consideration the age and comorbidities of the patient, CT-guided percutaneous microwave-thermal ablation was preferrable to surgery and a safe and highly effective local ablative technique with few side-effects.

Is transurethral needle ablation of prostate out of fashion? Outcomes of single session office-based transurethral needle ablation of prostate in patients with symptomatic benign prostatic hyperplasia.

Purpose: Transurethral needle ablation (TUNA) is a minimally invasive procedure for the treatment of symptomatic benign prostatic hyperplasia (BPH). Compared to transurethral resection of the prostate (TURP), office-based TUNA is an attractive alternative as it is minimally invasive and avoids general anaesthesia. The aim of this study is to evaluate the efficacy of single session office-based TUNA. Materials and Methods: Data of 121 patients who had undergone TUNA was retrieved from June 2008 to March 2017. Patients were followed-up with visits at 1, 3, 6, and 12-months with the International Prostate Symptom Score (IPSS), quality of life (QoL) scoring and uroflowmetry. Results: Patients were 39 to 85 years old. The prostate volumes were 20.00 to 96.90 mL with a median of 26.95 mL. The median IPSS score pre-TUNA was 19, median QOL score pre-TUNA was 4 and median maximum urinary flow (Qmax) pre-TUNA was 10.3 mL/s. There is 65% improvement of IPSS post-TUNA (p<0.001). There is 75% improvement of QOL post-TUNA QOL (p<0.001). There is 35% improvement of Qmax post-TUNA Qmax (p<0.001). The mean relapse-free survival for TUNA is 6.123 years. The 1st, 3rd, and 5th year relapse-free survival rate were 91.7%, 76.6% and 63.7% respectively. Conclusions: Our study is the first to investigate the use of a single-setting office-based TUNA requiring minimal sedation in the Asian community. Complication rates were low in our series, with no associated mortality. When applied to selected patients, TUNA is an effective and reasonably safe alternative for the treatment of symptomatic BPH.

The Treatment of Acne Scars, a 30-Year Journey.

Over the past 30 years, the treatment of acne scars has undergone changes that have been significantly influenced by the concurrent development of new devices. The advent of fractional resurfacing lasers was a watershed moment for acne scarring therapy. The author recounts a career history of considerations of acne scarring treatments as well as the literature supporting the experiences causing changes in practice. Fractional ablative and nonablative lasers, sublative radiofrequency, picosecond lasers, microneedling with and without radiofrequency and fillers are the bulk of the treatments covered, along with a discussion of combination therapy. A practical algorithm for acne scarring for selection of treatment modalities is presented.

The interaction between irreversible electroporation therapy (IRE) and embolization material using a validated vegetal model: an experimental study.

PURPOSE: Irreversible electroporation (IRE) is a nonthermal tumor ablation technique that induces cell apoptosis while preserving extracellular architecture. Surgical clips and embolic agents may lie adjacent to, or within, the target lesion. It is unknown to date if IRE causes degradation to the embolic agents or surgical clips that may have adverse effects to patients. We aimed to examine the effects of the IRE on the morphology of various embolic agents and the effects of these agents to the ablation field using a previously validated vegetal model. METHODS: Metallic surgical clips and various metallic and nonmetallic embolic agents were inserted within the center of the tuber ablation field. Additionally, clips were inserted on the edge and outside the ablation field. One tuber was ablated as a control. Ablation settings were based on previous published experiments. Tubers were imaged with magnetic resonance imaging (MRI) 18-24 hours after ablation and the ablated field dimensions were measured. Nonmetallic embolic agents were examined microscopically by the pathologist. RESULTS: Nonmetallic agents did not affect the ablation pattern. Metallic implants, however, caused arcing of the ablation margins. There was no macroscopic or microscopic degradation to the agents after IRE. CONCLUSION: The ablation zone arced in the presence of surgical clips at the edge or outside the ablation margins; therefore, nearby critical structures may be susceptible to the effects of IRE. Furthermore, there was no physical degradation of the embolic agents or surgical clips, and this may have importance when considering IRE ablation of previously embolized lesions in vivo.

Ablation outcome of irreversible electroporation on potato monitored by impedance spectrum under multi-electrode system.

BACKGROUND: Irreversible electroporation (IRE) therapy relies on pulsed electric fields to non-thermally ablate cancerous tissue. Methods for evaluating IRE ablation in situ are critical to assessing treatment outcome. Analyzing changes in tissue impedance caused by electroporation has been proposed as a method for quantifying IRE ablation. In this paper, we assess the hypothesis that irreversible electroporation ablation outcome can be monitored using the impedance change measured by the electrode pairs not in use, getting more information about the ablation size in different directions. METHODS: Using a square four-electrode configuration, the two diagonal electrodes were used to electroporate potato tissue. Next, the impedance changes, before and after treatment, were measured from different electrode pairs and the impedance information was extracted by fitting the data to an equivalent circuit model. Finally, we correlated the change of impedance from various electrode pairs to the ablation geometry through the use of fitted functions; then these functions were used to predict the ablation size and compared to the numerical simulation results. RESULTS: The change in impedance from the electrodes used to apply pulses is larger and has higher deviation than the other electrode pairs. The ablation size and the change in resistance in the circuit model correlate with various linear functions. The coefficients of determination for the three functions are 0.8121, 0.8188 and 0.8691, respectively, showing satisfactory agreement. The functions can well predict the ablation size under different pulse numbers, and in some directions it did even better than the numerical simulation method, which used different electric field thresholds for different pulse numbers. CONCLUSIONS: The relative change in tissue impedance measured from the non-energized electrodes can be used to assess ablation size during treatment with IRE according to linear functions.

Photothermal ablation of inflammatory breast cancer tumor emboli using plasmonic gold nanostars.

Inflammatory breast cancer (IBC) is rare, but it is the most aggressive subtype of breast cancer. IBC has a unique presentation of diffuse tumor cell clusters called tumor emboli in the dermis of the chest wall that block lymph vessels causing a painful, erythematous, and edematous breast. Lack of effective therapeutic treatments has caused mortality rates of this cancer to reach 20%-30% in case of women with stage III-IV disease. Plasmonic nanoparticles, via photothermal ablation, are emerging as lead candidates in next-generation cancer treatment for site-specific cell death. Plasmonic gold nanostars (GNS) have an extremely large two-photon luminescence cross-section that allows real-time imaging through multiphoton microscopy, as well as superior photothermal conversion efficiency with highly concentrated heating due to its tip-enhanced plasmonic effect. To effectively study the use of GNS as a clinically plausible treatment of IBC, accurate three-dimensional (3D) preclinical models are needed. Here, we demonstrate a unique in vitro preclinical model that mimics the tumor emboli structures assumed by IBC in vivo using IBC cell lines SUM149 and SUM190. Furthermore, we demonstrate that GNS are endocytosed into multiple cancer cell lines irrespective of receptor status or drug resistance and that these nanoparticles penetrate the tumor embolic core in 3D culture, allowing effective photothermal ablation of the IBC tumor emboli. These results not only provide an avenue for optimizing the diagnostic and therapeutic application of GNS in the treatment of IBC but also support the continuous development of 3D in vitro models for investigating the efficacy of photothermal therapy as well as to further evaluate photothermal therapy in an IBC in vivo model.

Interstitial microwave treatment for cancer: historical basis and current techniques in antenna design and performance.

The use of microwaves (MW) for thermal cancer treatment began in the late 1970s. At first, hyperthermia was induced by using single antennas applied interstitially. This was followed by arrays of multiple interstitial antennas driven synchronously at 915 or 2450 MHz. This early work focused on hyperthermia as an adjuvant therapy, but more recently has evolved into a thermally ablative monotherapy. Increased power required to thermally ablate tissues required additional developments such as internally cooled antennas. Larger tumours have also been ablated with MW antenna arrays activated synchronously or non-synchronously. Numerical modelling has provided clinical treatment planning guidance and device design insight throughout this history. MW thermal therapy systems, treatment planning, navigation and image guidance continue to evolve to provide better tools and options for clinicians and patients in order to provide targeting optimisation with the goal of improved treatment for the patient and durable cancer eradication. This paper reviews the history and related technological developments, including antenna design, of MW heating for both hyperthermia and ablation.

How I do it: Aquablation of the prostate using the AQUABEAM system.

Benign prostatic hyperplasia (BPH) represents one of the most common conditions encountered in urological practice. For many years, transurethral resection of the prostate (TURP) has been considered the gold standard for surgical management of symptoms in prostates of 30 cc-80 cc. Although TURP provides excellent functional outcomes, there is significant morbidity associated with the procedure, particularly with regards to bleeding, electrolyte imbalance and sexual dysfunction. Emerging technologies aim to maintain the excellent functional results of TURP whilst decreasing the adverse events experienced by the patient. Aquablation is a novel therapy using a high-velocity waterjet and real-time ultrasound imaging with robotic assistance for targeted removal of prostate tissue. We present our experiences with this new technique, the equipment required and steps involved.

Using ferromagnetic nanoparticles with low Curie temperature for magnetic resonance imaging-guided thermoablation.

INTRODUCTION: Magnetic nanoparticles (NPs) represent a tool for use in magnetic resonance imaging (MRI)-guided thermoablation of tumors using an external high-frequency (HF) magnetic field. To avoid local overheating, perovskite NPs with a lower Curie temperature (T c) were proposed for use in thermotherapy. However, deposited power decreases when approaching the Curie temperature and consequently may not be sufficient for effective ablation. The goal of the study was to test this hypothesis. METHODS: Perovskite NPs (T c =66°C-74°C) were characterized and tested both in vitro and in vivo. In vitro, the cells suspended with NPs were exposed to a HF magnetic field together with control samples. In vivo, a NP suspension was injected into a induced tumor in rats. Distribution was checked by MRI and the rats were exposed to a HF field together with control animals. Apoptosis in the tissue was evaluated. RESULTS AND DISCUSSION: In vitro, the high concentration of suspended NPs caused an increase of the temperature in the cell sample, leading to cell death. In vivo, MRI confirmed distribution of the NPs in the tumor. The temperature in the tumor with injected NPs did not increase substantially in comparison with animals without particles during HF exposure. We proved that the deposited power from the NPs is too small and that thermoregulation of the animal is sufficient to conduct the heat away. Histology did not detect substantially higher apoptosis in NP-treated animals after ablation. CONCLUSION: Magnetic particles with low T c can be tracked in vivo by MRI and heated by a HF field. The particles are capable of inducing cell apoptosis in suspensions in vitro at high concentrations only. However, their effect in the case of extracellular deposition in vivo is questionable due to low deposited power and active thermoregulation of the tissue.

New technologies in benign prostatic hyperplasia management.

PURPOSE OF REVIEW: Surgical debulking of the adenoma/transition zone has been the fundamental principle which underpins transurethral resection of the prostate - still acknowledged to be the gold-standard therapy for benign prostatic hyperplasia (BPH). However, there has been a recent resurgence in development of new BPH technologies driven by enhanced understanding of prostate pathophysiology, development of new ablative technologies, and the need for less morbid alternatives as the mean age and complexity of the treatment population continues to increase. The objective of this review is to highlight new BPH technologies and review their available clinical data with specific emphasis on unique features of the technology, procedural effectiveness and safety, and potential impact on current treatment paradigms. RECENT FINDINGS: New technologies have emerged that alter the shape of the prostate to decrease urinary obstruction and enhance delivery of a lethal thermal dose by steam injection into the transition zone of the prostate. Energy can be delivered to the prostate via a beam of high-pressure saline or focused acoustic energy to mechanically disintegrate prostate tissue. Methods of cell death are being targeted with selectivity by the arterial supply with embolization and specific to prostate cells via injectable biological therapies. SUMMARY: A number of new technologies are at various stages of development and improve on the transurethral resection of the prostate paradigm by moving closer to the ideal BPH therapy which is definitive, can be performed in minutes, in the office setting, with only local anesthesia and oral sedation.

Fractional treatment of aging skin with Tixel, a clinical and histological evaluation.

OBJECTIVE: This study presents clinical results of Tixel, a new fractional skin resurfacing system based on thermo-mechanical ablation technology. Tixel employs a hot (400°C) metallic tip consisting of 81 pyramids. Treatment is performed by rapidly advancing the tip to the skin for a preset tip-skin contact duration. Thermal energy transfer to the skin creates micro-craters by evaporation. METHODS: Treatment results with tip types, D and S, with high and low thermal conductivity, were evaluated. Twenty-six subjects received three facial treatments, with 4-5-week intervals between treatments, without analgesia or cooling. In addition, histopathologies of Tixel and CO2 laser were performed. RESULTS: Crater properties are related to contact duration and to thermal conductivity. The D tip created char-free ablative craters 100-320 µm wide with a thermal zone 100-170 µm deep. The S tip created non-ablative coagulation preserving the epidermis. Skin complexion improvement was achieved in all subjects; average treatment pain of 3.1/10, downtime of 0-1 days, and erythema clearance of 3.5 days. Subject's satisfaction was 75% and wrinkle attenuation was achieved in 75% of the cases. There was no incidence of bleeding, scarring, or post-inflammatory hyperpigmentation. CONCLUSIONS: Tixel may be used safely for ablative and non-ablative resurfacing with low pain, low downtime, and quick healing.

Laser and energy-based devices' complications in dermatology.

Laser dermatology is an ever-expanding part of the specialty used extensively for both aesthetic and medical conditions. Advances in laser technology have led to an expansion in the number of devices available, with as a consequence an increase in the total number of complications. Fortunately, the current technology has improved greatly which adds to the safety profile of such devices; nevertheless, thorough knowledge of laser complications and how to avoid them is paramount for any practitioner who uses such technology.

Laparoscopic microwave thermosphere ablation of malignant liver tumors: An analysis of 53 cases.

BACKGROUND AND OBJECTIVES: Microwave thermosphere ablation (MTA) is a new technology that is designed to create spherical zones of ablation using a single antenna. The aim of this study is to assess the results of MTA in a large series of patients. METHODS: This was a prospective study assessing the use of MTA in patients with malignant liver tumors. The procedures were done mostly laparoscopically and ablation zones created were assessed for completeness of tumor response, spherical geometry and recurrence on tri-phasic CT scans done on follow-up. RESULTS: There were a total of 53 patients with an average of 3 tumors measuring 1.5 cm. Ablations were performed laparoscopically in all but eight patients. Morbidity was 11.3% (n = 6), and mortality zero. On postoperative scans, there was 99.3% tumor destruction. Roundness indices A, B, and transverse were 1.1, 1.0, and 0.9, respectively. At a median follow-up of 4.5 months, incomplete ablation was seen in 1 of 149 lesions treated (0.7%) and local tumor recurrence in 1 lesion (0.7%). CONCLUSIONS: The results of this series confirm the safety and feasibility of MTA technology. The 99.3% rate of complete tumor ablation and low rate of local recurrence at short-term follow up are promising.

FDA MAUDE data on complications with lasers, light sources, and energy-based devices.

BACKGROUND AND OBJECTIVE: It is essential for physicians to be fully informed regarding adverse events and malfunctions associated with medical devices that occur in routine practice. There is limited information on this important issue in the medical literature, and it is mostly based on initial studies and case reports. More advanced knowledge regarding device adverse events is necessary to guide physicians towards providing safe treatments. The FDA requires that manufacturers and device users submit medical device reports (MDRs) for suspected injuries from device use or malfunction. The database of MDRs, entitled Manufacturer and User Facility Device Experience (MAUDE) enables the FDA to monitor device performance and identify potential safety issues. STUDY DESIGN/MATERIALS AND METHODS: We employed the following search strategy to identify reported adverse events. We searched the MAUDE electronic database on the FDA website in December 2013: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm We collected all reported cases between 1991 and December 2013. The search terms utilized included a comprehensive list of device manufacturers, specific product names, and the wavelengths/technology of the devices used in the field of dermatology. RESULTS: Our search yielded 1257 MDRs. Forty-five MDRs were excluded due to insufficient data. The data is broken down into the adverse events observed, such as, but not limited to: blistering, burns, scarring, dyschromia, fat loss, and nerve palsy. The MDRs describe the adverse event and attempt to determine if it was related to device malfunction versus operator error. Radiofrequency devices, diode lasers, and intense pulsed light devices were the most commonly reported devices related to injuries. CONCLUSION: 1257 MDRs, from a myriad of devices used in dermatology, have been reported to the FDA as of December 2013. Despite the underreporting of adverse events, the MAUDE database is an untapped resource of post-market surveillance of medical devices. The database can offer additional information, which combined with the initial device studies and published case reports from our colleagues, will help raise awareness and improve patient safety.

Atrioventricular node ablation in Langendorff-perfused porcine hearts using carbon ion particle therapy: methods and an in vivo feasibility investigation for catheter-free ablation of cardiac arrhythmias.

BACKGROUND: Particle therapy, with heavy ions such as carbon-12 ((12)C), delivered to arrhythmogenic locations of the heart could be a promising new means for catheter-free ablation. As a first investigation, we tested the feasibility of in vivo atrioventricular node ablation, in Langendorff-perfused porcine hearts, using a scanned 12C beam. METHODS AND RESULTS: Intact hearts were explanted from 4 (30-40 kg) pigs and were perfused in a Langendorff organ bath. Computed tomographic scans (1 mm voxel and slice spacing) were acquired and (12)C ion beam treatment planning (optimal accelerator energies, beam positions, and particle numbers) for atrioventricular node ablation was conducted. Orthogonal x-rays with matching of 4 implanted clips were used for positioning. Ten Gray treatment plans were repeatedly administered, using pencil beam scanning. After delivery, positron emission tomography-computed tomographic scans for detection of ß(+) ((11)C) activity were obtained. A (12)C beam with a full width at half maximum of 10 mm was delivered to the atrioventricular node. Delivery of 130 Gy caused disturbance of atrioventricular conduction with transition into complete heart block after 160 Gy. Positron emission computed tomography demonstrated dose delivery into the intended area. Application did not induce arrhythmias. Macroscopic inspection did not reveal damage to myocardium. Immunostaining revealed strong γH2AX signals in the target region, whereas no γH2AX signals were detected in the unirradiated control heart. CONCLUSIONS: This is the first report of the application of a (12)C beam for ablation of cardiac tissue to treat arrhythmias. Catheter-free ablation using 12C beams is feasible and merits exploration in intact animal studies as an energy source for arrhythmia elimination.

Diode laser ablation of prostate and channel transurethral resection of prostate in patients with prostate cancer and bladder outlet obstruction symptoms.

PURPOSE: To evaluate the efficacy of diode laser ablation of prostate for treating lower urinary tract symptoms (LUTS) in patients with locally advanced prostate cancer and comparing results with palli­ative transurethral resection of prostate (pTURP). MATERIALS AND METHODS: Thirty-six known cases of locally advanced prostate cancer with a maximum urinary flow rate (Qmax) of 12 mL per second or less and an International Prostate Symptom Score (IPSS) of 20 or more were included in this study. Patients were randomized into two groups. The first group underwent pTURP and for the second group diode laser ablation of prostate was done. In 6 months post-operative follow up, patients were evaluated for IPSS, post void residual (PVR) urine volume, Qmax and possible complications such as urethral stricture or urinary incontinence. RESULTS: Postoperatively, mean IPSS was 11.1 ± 4.1 in TURP group and 11.7 ± 3.6 in laser group (P = .64). Mean PVR was 18.4 ± 3.5 mL in TURP group and 17.7 ± 6.3 mL in laser group (P = .68). Mean Qmax in TURP and laser groups were measured 20.1 ± 4.5 mL/s and 19.4 ± 2.6 mL/s, respectively (P = .57). While there was a significant improvement in IPSS and Qmax and PVR in both groups, statisti­cal analysis did not show any significant difference postoperatively between pTURP and laser groups. CONCLUSION: Diode laser ablation of prostate and pTURP, both improved significantly IPSS, PVR and Qmax. But hospital stay and post-operative catheterization time was less in laser group.