Periurethral transurethral microwave thermotherapy for the treatment of benign prostatic hyperplasia: an interim 1-year safety and efficacy analysis using the thermatrx TMx-2000.

Transurethral microwave thermotherapy (TUMT) represents an accepted minimally invasive approach to the management of patients with benign prostatic hyperplasia (BPH). The TherMatrx TMx-2000 represents a further evolution in TUMT technique. This device uses periurethral transurethral microwave thermotherapy (P-TUMT) technology to directly target the BPH tissue adjacent to the prostatic urethra by using a catheter without a urethral-cooling surface. This article provides a technical review of the device and describes the results of a randomized, controlled multicenter study of P-TUMT for the treatment of symptomatic BPH. A discussion of the physiologic effects of P-TUMT is presented and compared to conventional TUMT. A comparison of P-TUMT to contemporary TUMT series in relation to efficacy and complications is also described. This study concludes that P-TUMT using the TherMatrx TMx-2000 device represents a minimally invasive, efficacious, and well-tolerated treatment for symptomatic BPH.

Prostate cancer detection, characterization, and clinical outcomes in men aged 70 years and older referred for transrectal ultrasound and prostate biopsies.

OBJECTIVES: To evaluate the diagnostic findings and treatment options chosen in men aged 70 years and older referred for prostate biopsy. METHODS: Age, prostate-specific antigen (PSA), biopsy pathology, clinical stage, treatment pursued, and treatment outcome were analyzed in 210 men age 70 years and older referred for transrectal ultrasound and prostate biopsies. All patients were followed for a mean of 46.9 months (range 28 to 63). RESULTS: Cancer was found in 120 (56.8%) of the patients. The cancer detection rate was significantly higher (81.0%) in patients aged 80 years and older than those younger than 80 years. Cancer patients aged 80 years and older had a higher rate of poorly differentiated cancer (64.7%) compared with the 70 to 74-year-olds (33.3%) and 75 to 79-year-olds (32.1%). The patients aged 80 years and older also had a larger proportion of high-stage cancer. The patients younger than 80 years had a significantly higher incidence of stable/falling PSA with treatment compared with the older patients. Of the 210 patients, 41 (19.4%) died within 5 years of the diagnostic procedure; 3 died of prostate cancer. The death rate was not significantly different among the three age groups evaluated. None of the patients aged 80 years and older died of prostate cancer. CONCLUSIONS: Patients aged 80 years and older who are diagnosed with prostate cancer are less likely to respond well to treatment and usually die of unrelated causes. Aggressive diagnosis, staging, and treatment in octogenarians should be guided by the patients' symptoms, overall health, and personal preferences.

Bacteremia and bacteriuria after transrectal ultrasound guided prostate biopsy.

PURPOSE: We determined the incidence and predisposing factors of bacteremia and bacteriuria after prostate biopsy with specific emphasis on the value of a pre-biopsy enema. MATERIALS AND METHODS: We randomized 50 men undergoing ultrasound and biopsy to rule out prostate cancer to receive a preoperative (25) or no (25) enema. Preoperatively urine was obtained for culture, and questionnaires regarding urological history and voiding symptoms were completed. The initial prostate biopsy, biopsy needle, and postoperative urine and blood specimens were cultured. The following day a symptom questionnaire was completed. RESULTS: Bacterial growth in post-procedure cultures did not correlate with the number of biopsies, prostate specific antigen, obstructive voiding symptoms, prostate volume, cancer or post-biopsy hematuria. Bacteriuria was noted in 44% of the cases and bacteremia was present in 16% of the patients, of whom 87.5% did not receive an enema (p = 0.0003). Only 1 patient had chills and fever greater than 37.5C, requiring additional antibiotics. On the followup questionnaire 12% of patients described dysuria, including 84% with bacteriuria after biopsy. CONCLUSIONS: Bacteremia and bacteriuria after multiple biopsies are common but usually asymptomatic. Bacteria is apparently introduced into the urine and/or blood from the rectum via the biopsy needle, which may be minimized by a pre-biopsy enema. Dysuria or a history of urinary tract infection did not predict problems after biopsy.

Holmium laser versus transurethral resection of the prostate: a randomized prospective trial with 1-year followup.

PURPOSE: The high-powered holmium:YAG laser can be used for incision, ablation and resection of the prostate. The technique of holmium laser resection of the prostate is compared to transurethral prostatic resection for surgical management of benign prostatic hyperplasia in this prospective randomized study. MATERIALS AND METHODS: A total of 120 urodynamically obstructed cases were randomized to holmium laser or transurethral prostatic resection. All eligible patients were assessed preoperatively and at 3 weeks, and 3, 6 and 12 months postoperatively with an American Urological Association symptom score, peak urinary flow rate, and questionnaires concerning sexual function and continence. Preoperative pressure flow study, ultrasound prostate volume assessment and post-void residual volume measurement were repeated at the 6-month visit. All complications were noted. RESULTS: Holmium laser and transurethral resections resulted in significant improvements in symptom score, quality of life score, peak urinary flow rate and post-void residual urine measurements. Operating time was significantly longer in the holmium group but nursing contact time, catheter time and hospital stay were significantly less compared to the transurethral prostatic resection group. Urodynamic results were equivalent at 6 months. There were fewer side effects in the holmium group. Effects on continence, potency and symptoms were similar with 1-year followup. CONCLUSIONS: Holmium and transurethral resections of the prostate appear to be equivalent in surgical management of bladder outflow obstruction due to benign prostate hyperplasia. Perioperative morbidity was less in the holmium group.

Side-firing Neodymium:YAG laser prostatectomy.

Not until 1991 did laser therapy for benign prostatic hyperplasia become a feasible option for the practicing urologist. Prior to the development of side firing free beam laser delivery devices contact Neodymium:YAG, laser therapy for BPH was of limited applicability. Since 1991, refinements in laser device technology have allowed the urologist to expand the potential for Neodymium:YAG coagulative prostatectomy. Multiple studies over the past five years have demonstrated equivalence in efficacy and safety to conventional electrocautery TURP. Holmium:YAG laser technology may be a significant advance again on free beam side firing Neodymium:YAG laser prostatectomy.

Renal masses presenting 25 and 50 years following blunt renal trauma.

The long-term consequences of blunt renal trauma are not well described. We report on 2 patients with a history of blunt renal trauma who presented with radiographically detected renal masses suspicious for renal tumor. Both patients suffered blows to the kidney during boxing matches followed by flank pain and hematuria. The injuries occurred 25 and 50 years prior to the detection of renal masses. Subsequent nephrectomy and histopathological evaluation revealed benign dystrophic renal tissue. These presentations represent probable long-term sequelae of blunt renal trauma.

Correlation of transrectal ultrasound measurements of prostate and transition zone size with symptom score, bother score, urinary flow rate, and post-void residual volume.

OBJECTIVES: To assess the correlation of total prostatic size and prostate transition zone dimensions with various measurements of the severity of bladder outlet obstruction secondary to benign prostatic hyperplasia. METHODS: Prostate-specific antigen, creatinine, American Urological Association symptom score, bother score, urinary history, uroflowmetry, and post-void residual urine volume determination was followed by measurement of the prostate gland and transition zone on transrectal ultrasound images in 136 men undergoing systematic prostate biopsies. Patients were divided into five groups based on past urinary tract treatment history and the presence of prostate cancer on the biopsies. The total prostate and transition zone dimensions, as well as calculated prostate and transition zone volumes, were compared by Pearson correlation with both the subjective and objective voiding parameters in each patient group. RESULTS: The transition zone dimensions correlated positively with American Urological Association symptom score, bother score, and post-void residual urine volume and correlated negatively with maximum and mean flow rates, particularly in patients with no history of prostate surgery, alpha-blocker administration, urinary infections, irritative voiding symptoms, or prostate cancer. CONCLUSIONS: Transrectal ultrasound measurements of transition zone dimensions correlate better than total prostatic dimensions or calculated prostatic or transition zone volumes with the severity of benign prostatic hyperplasia. Of these, the transverse transition zone dimension demonstrated the best correlation; however, this correlation is probably not adequate for clinical utility.

Application of the holmium:YAG laser for prostatectomy.

OBJECTIVE: The authors review the current knowledge regarding the application of the Holmium: YAG laser for prostatectomy. SUMMARY BACKGROUND DATA: Conventional surgical therapies for benign prostatic hyperplasia (BPH) are effective but associated with relatively high morbidity. Laser prostatectomy, using either Neodymium:YAG or potassium-titanyl-phosphate lasers, has emerged as a new and much safer operative approach to relieve symptoms of benign prostatic hyperplasia. However, these laser wavelengths possess key disadvantages that have limited their acceptability and dissemination in everyday urologic practice. METHODS: THE authors review their own extensive experience in the development of clinical application of Holmium: YAG laser technology for prostatectomy, as well as the published reports in the current medical literature now dealing with this subject. RESULTS: In multiple clinical trials, Holmium:YAG laser resection of the prostate has proven efficacious in relieving symptomatic BPH. Both objective urodynamic measures of voiding outcomes and symptomatic improvement have been shown to be equivalent to standard electrocautery resection of the prostate. At the same time, these studies have demonstrated the superior safety and hemostasis of Holmium:YAG laser prostatectomy compared to electrocautery resection, similar to prior laser prostatectomy procedure. Unlike prior forms of laser prostatectomy, Holmium:YAG laser resection of the prostate acutely removes all obstructing prostate tissue, so that the postoperative catheterization requirement is typically only overnight and improvement in voiding is immediate. Current operative techniques and the latest technological developments to facilitate Holmium:YAG laser prostatectomy are described. CONCLUSIONS: Holmium: YAG laser prostatectomy combines the best features of prior laser prostatectomy technologies, including minimal complications and morbidity, with the efficacy and immediacy of voiding outcomes associated with conventional electrocautery resection of the prostate.

Holmium:yttrium-aluminum-garnet laser prostatectomy.

As alternatives to transurethral resection of the prostate for treatment of benign prostatic hyperplasia, various types of laser prostatectomy-most notably, neodymium:yttrium-aluminum-garnet (YAG) and potassium titanyl phosphate laser procedures-have proved to be associated with considerably less morbidity (for example, bleeding, need for transfusion, intraoperative fluid absorption, and postoperative incontinence). Despite these advantages, certain disadvantages (need for prolonged postoperative catheterization and delayed symptomatic improvement) prompted investigation of the holmium:YAG laser for performance of prostatectomy. The holmium:YAG laser is highly absorbed by tissue water and causes rapid vaporization of exposed soft tissue. After initial studies in canine prostates and human prostatectomy specimens, clinical studies with the holmium:YAG laser showed no fluid absorption, appreciable blood loss, or complications, and voiding outcomes were improved immediately, similar to the result with transurethral resection of the prostate. In addition, the holmium:YAG laser has been used to perform transurethral incision of the prostate rapidly and hemostatically. Holmium laser resection of the prostate is a safe and efficacious procedure for relief of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia.

Holmium laser resection of the prostate versus neodymium:yttrium-aluminum-garnet visual laser ablation of the prostate: a randomized prospective comparison of two techniques for laser prostatectomy.

OBJECTIVES: To directly compare holmium laser resection of the prostate (HoLRP) with neodymium:yttrium-aluminum-garnet visual laser ablation of the prostate (VLAP), which represent two fundamentally different methods of laser prostatectomy. METHODS: In a randomized, prospective comparison, a total of 44 men with symptomatic benign prostatic hyperplasia (BPH) were treated with either HoLRP or VLAP. Standard preoperative assessment included American Urological Association (AUA) symptom score, peak urinary flow rates (Qmax), ultrasound prostate volume, and residual urine measurements. Pressure-flow urodynamics were performed preoperatively and at 3 months postoperatively. Intraoperative and perioperative factors were assessed. The patients were followed at 1, 3, 6, and 12 months following the procedure. RESULTS: There were no significant differences between the patient groups for any preoperative parameter. The mean total operating time was longer in the HoLRP group (52 minutes) compared with the VLAP group (41 minutes) (P <0.01). The mean catheter times were 1.4 days (HoLRP) and 11.6 days (VLAP) (P <0.001). These times included the 9% of patients undergoing HoLRP and 36% of patients undergoing VLAP who required recatheterization. Immediate postoperative dysuria scores were higher in the VLAP group compared with the HoLRP group. There were no significant differences in AUA scores between the two treatment groups at any postoperative interval. The Qmax values were greater at follow-up in the HoLRP group, but statistical significance was not achieved at 12 months. However, both PdetQmax and Schäfer grade measurements taken at 3 months postoperatively were significantly lower in the patients undergoing HoLRP. Three patients (14%) required reoperation in the VLAP treatment arm but no patient who underwent HoLRP has required reoperation to date. CONCLUSIONS: HoLRP results in significantly improved patient outcomes compared to VLAP.

Long-term followup of and patient satisfaction with the Dynaflex self-contained inflatable penile prosthesis.

PURPOSE: We analyzed our experience with the Dynaflex* self-contained inflatable penile prosthesis to define specific complication rates and patient satisfaction in the long term. MATERIALS AND METHODS: From October 1990 through October 1994, 62 men underwent implantation of a Dynaflex prosthesis. Mean and median time since implantation was 50 and 53 months, respectively (minimum 24). In addition to standard followup and tabulation of complications, patients were contacted and interviewed regarding satisfaction with the prosthesis. RESULTS: Mechanical device failures occurred in 9.7% of cases with a mean time to failure of 40 months in 6 prostheses. An additional 16.1% of patients had an unsuccessful outcome due to dissatisfaction with the Dynaflex. Of the patients with a functional Dynaflex prosthesis contacted at the time of this review 88.1% expressed satisfaction. CONCLUSIONS: Mechanical failure rates for the Dynaflex prosthesis are comparable to those previously reported for multicomponent inflatable penile prostheses. Patient dissatisfaction, mainly due to difficulty in operating the Dynaflex inflation and deflation mechanisms, is much higher than for multicomponent inflatable penile prostheses. However, in patients who are successful in mastering operation of the Dynaflex satisfaction rates are high. Careful patient selection, and extended training and education efforts are the keys to maximizing successful outcomes with the Dynaflex prosthesis.

Holmium: YAG laser resection of prostate (HoLRP) for patients in urinary retention.

We examined the holmium:YAG (Ho:YAG) laser as a tool to perform acute resection of obstructing prostatic tissue in the subgroup of men with benign prostatic hyperplasia (BPH) who present in urinary retention. A total of 36 men presented in acute urinary retention requiring catheterization before undergoing Ho:YAG laser resection of the prostate (HoLRP). Their mean age was 67 years. The mean laser energy delivery was 102 kJ (range 42-315 kJ). The mean postoperative catheterization time was 1.5 days (range 1-8 days), and only 3 men required a catheter for more than 48 hours. There were no acute perioperative complications. Improvement in voiding was immediate and sustained through 6 months of follow-up. At 6 months, the mean peak urinary flow rate was 22.5 mL/sec, and the AUA Symptom Index Score was 5.7. A meatal stricture requiring dilation in one man represents the sole late complication observed in this series. Late recurrence of urinary retention has occurred in two men who had contributing medical problems, for an overall treatment failure rate of 5.6%. Thus, HoLRP represents an effective surgical therapy for patients with bladder outlet obstruction presenting in urinary retention. Morbidity is minimal compared with electrocautery resection, while the efficacy and immediacy of voiding improvement appear similar.

Prospective multicenter ProLase II clinical trial of neodymium:yttrium-aluminum-garnet laser prostatectomy.

OBJECTIVES: To assess the clinical efficacy of neodymium:yttrium-aluminum-garnet (YAG) laser coagulation prostatectomy using a broad-angle, divergent-beam, side-firing fiber. METHODS: Eighty adult men with voiding symptoms caused by benign prostatic hyperplasia were enrolled in a prospective multicenter study of free-beam neodymium:YAG laser prostatectomy performed with the ProLase II side-firing delivery fiber. Voiding outcomes were assessed at 3, 6, and 12 months postoperatively. RESULTS: At 1-year follow-up, peak urinary flow rates were increased by 105%, postvoid residual urine volumes had decreased by 38%, and the AUA symptom index had decreased by 60%. Serious treatment-related complications occurred in 3 of 80 patients (3.8%). The reoperation rate through 1-year follow-up was 2.7%. CONCLUSIONS: Neodymium:YAG laser prostatectomy performed with the ProLase II delivery fiber has proven safe and efficacious with durable results through 1 year in the relief of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia.

Neodymium:YAG laser coagulation prostatectomy for patients in urinary retention.

Urinary retention necessitating catheterization is the presenting complaint for a significant minority of men requiring surgical therapy for bladder outlet obstruction. A total of 67 men presented in acute or chronic urinary retention and underwent Nd:YAG laser prostatectomy. Their mean age was 71 years, the mean estimated excess transition zone tissue was 40 g, and the mean laser energy delivery was 48 kJ. The median postoperative catheterization time was 10 days. Five men required catheterization for > or = 6 weeks, and in five men, the catheter was removed within 48 hours. In four men (6%), a successful postoperative voiding trial was never achieved. Postoperatively, mean voiding measures for the remaining 63 men were a peak flow rate of 16.1 mL/sec, a post void residual volume of 113 mL, and an AUA Symptom Index score of 7.7. Complications included urinary tract infection in two, urethral stricture in one, and bladder neck contracture in 3 men. Four men have subsequently elected additional treatment for bladder outlet obstruction (two transurethral resections, one repeat laser, and one terazosin), for an overall treatment failure rate of 6 of 67 (9%), including the two men who remain catheterized. Laser coagulation prostatectomy produces little or no acute morbidity with a successful long-term voiding outcome in the majority of men requiring treatment for acute or chronic urinary retention.

Acucise incision of ureteroenteric strictures after urinary diversion.

Four ureteroenteric strictures in three men were incised using the Acucise catheter. All patients had undergone urinary diversion after radical cystectomy. One patient had a solitary kidney, and one patient had bilateral ureteroenteric strictures. Two patients were morbidly obese. One stricture involved the right ureter, and the left ureteral anastomosis was strictured in all three cases. After careful radiographic and endoscopic assessment of local periureteral anatomy, Acucise incision was performed successfully for all four strictures without complications. All incised ureteroenteric anastomoses have remained patent through postoperative follow-ups of 11, 27, and 28 months, as judged by retrograde loopograms and diuretic renograms. Acucise incision of ureteroenteric stricture after urinary diversion provides an efficient and effective endourologic management option in these difficult cases. Emphasizing the need for careful preincision anatomic evaluation, this technologic approach can be employed even in the management of left ureteroenteric strictures.

Routine transition zone and seminal vesicle biopsies in all patients undergoing transrectal ultrasound guided prostate biopsies are not indicated.

PURPOSE: Transrectal ultrasound guided biopsies of the transition zone and seminal vesicles have been useful in select patients. More widespread use of these additional biopsies has been proposed. The efficacy of routine transition zone and seminal vesicle biopsies was examined. MATERIALS AND METHODS: From January 1988 to October 1994, 736 transrectal ultrasound guided systematic sextant biopsies were performed. From October 1994 to July 1995, 161 consecutive patients underwent transrectal ultrasound with systematic sextant, transition zone and seminal vesicle biopsies. RESULTS: Of the 736 patients undergoing only sextant biopsies 309 (42.0%) had cancer and 24 (3.3%) required repeat biopsy, compared to 55 (34.2%) and 4 (2.5%) of 161 undergoing combined sextant, transition zone and seminal vesicle biopsies. Prostate cancer was found only in the systematic sextant biopsies in 43 of the former 55 patients (78.2%), and in the transition zone and systematic sextant biopsies in 11 (20.0%). One patient (1.8% of patients with cancer or 0.6% of all 161 patients) had cancer in only the anterior biopsies and 6 (10.9 and 3.7%, respectively) had cancer involving the seminal vesicles. CONCLUSIONS: Routine transition zone and seminal vesicle biopsies in all patients undergoing transrectal ultrasound guided systematic sextant biopsies are not warranted.

Addition of a second urethral cuff to enhance performance of the artificial urinary sphincter.

PURPOSE: Stress urinary incontinence may persist in approximately 15% of men following implantation of a standard artificial urinary sphincter. The ability of a second urethral cuff to provide satisfactory continence without additional operative complications was investigated. MATERIALS AND METHODS: A second urethral cuff was placed to enhance performance of the artificial urinary sphincter in 5 men with stress urinary incontinence following radical prostatectomy. A stainless steel 3-way tubing connector allowed for addition of a second cuff to the standard artificial urinary sphincter without the kinking problems previously observed with a flexible 3-way connector. In 4 consecutive men a second cuff was added at operative revision of an existing artificial urinary sphincter that had failed to produce satisfactory continence. A double cuff artificial sphincter was placed initially in 1 man. RESULTS: Of 5 men 4 had satisfactory and 1 had improved continence with the double cuff artificial urinary sphincter. The stainless steel 3-way tubing connector eliminated kinking complications. CONCLUSIONS: Implantation of a second urethral cuff can provide satisfactory urinary continence in men with an artificial urinary sphincter and persistent incontinence. Placement of a double cuff artificial urinary sphincter may also represent appropriate initial intervention in men with significant stress urinary incontinence.

Holmium:YAG laser prostatectomy: results of U.S. pilot study.

The holmium:YAG (Ho:YAG) laser wavelength's ability to vaporize and incise soft tissue offers potential advantages for prostatectomy compared with the Nd:YAG laser, which primarily produces tissue coagulation. In this initial U.S. trial, Ho:YAG laser prostatectomy was performed in 20 men, including 2 men treated immediately prior to radical prostatectomy to assess Ho:YAG laser tissue effects in the prostate. A total of 18 men were treated for clinically symptomatic bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH). Estimated excess BPH tissue averaged 24 g (range 5-50 g). A mean of 129 kJ of Ho:YAG laser energy was delivered, combined with a mean of 11 kJ of Nd:YAG energy to provide supplemental coagulation for hemostasis. The mean operative time was 1 hour 34 minutes. No significant intraoperative changes in hematocrit or serum electrolytes were documented. No perioperative or late complications occurred. The mean postoperative catheterization time was 1.4 days. Of the 18 patients, 16 (90%) underwent a successful voiding trial on the first postoperative morning. Immediate improvement in voiding, comparable to that seen after transurethral electrocautery resection of the prostate (TURP), was reported by all patients. Ho:YAG laser resection of the prostate appears to be a useful surgical technique associated with minimal morbidity and immediate improvement in voiding.