Transurethral interstitial laser coagulation of the prostate and transurethral microwave thermotherapy vs transurethral resection or incision of the prostate: results of a randomized, controlled study in patients with symptomatic benign prostatic hyperplasia.

OBJECTIVE: To compare the efficacy and frequency of complications of transurethral interstitial laser coagulation (ILC) and transurethral microwave thermotherapy (TUMT) with transurethral resection or incision of the prostate (TURP/TUIP) in patients with symptomatic benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Forty-eight patients were randomized to undergo ILC, 46 to TUMT and 24 to TURP/TUIP; they were followed for 6 months and the outcome analysed on an intention-to-treat basis. RESULTS: At 6 months the symptom scores and maximum urinary flow rate (Qmax) had improved significantly in all groups. At 6 months the mean symptom score was 9.2 in both experimental groups and 6.8 in the control group (P > 0.05); the mean Qmax was 20.6 mL/s in the control group, 16.2 in the ILC group (P > 0.05 vs control) and 13.2 in the TUMT group (P < 0.05 vs. the control group). In the TUMT group patients developing urinary retention afterward had a significantly greater increase in Qmax than those who did not. The types of complications in the three groups varied. Urinary tract infection occurred frequently in the experimental groups, especially after ILC, whereas the 'well-known' complications of TURP occurred in the control group. Overall, 36% in the ILC, 54% in the TUMT and 73% in the control group had no complications (retrograde ejaculation excluded) during the first 6 months. One patient in the TUMT group underwent TURP after 3 months, whereas no patients in the ILC or the con-trol group were re-treated for BPH within the first 6 months. CONCLUSION: In the short term both ILC and TUMT are reasonable alternatives to standard transurethral surgery for symptomatic BPH, where the reduction of symptoms is the primary goal of treatment. However, both ILC and TUMT were associated with morbidity, although the complication profiles differed from those after TURP/TUIP. Both ILC and TUMT seem advantageous in some patients because of the reduced risk of bleeding and the eliminated risk of TUR syndrome, and because TUMT only requires local anaesthesia. Thus, as neither treatment is better in all aspects, the advantages of one technique over the other must be weighed when deciding how to treat each patient.

Cost-effectiveness of new treatments for benign prostatic hyperplasia: results of a randomized trial comparing the short-term cost-effectiveness of transurethral interstitial laser coagulation of the prostate, transurethral microwave thermotherapy and standard transurethral resection or incision of the prostate.

OBJECTIVES: To compare the short-term cost-effectiveness of ILC and TUMT with that of transurethral resection or incision of the prostate in patients with symptomatic benign prostatic hyperplasia. MATERIAL AND METHODS: One hundred and eighteen patients were randomized to ILC, TUMT and TUR-P/TUI-P in 2:2:1 fashion. The use of resources within the first 6 months of follow-up were measured and the cost of treatment for each patient were calculated. A few parameters, primarily related to the time spent by the staff, were measured only in a subgroup of patients. A cost-effectiveness analysis was performed based on the average calculated cost and change in I-PSS found in each group. For costly resources a sensitivity analysis was performed. RESULTS: At 6 months the cost was lowest in the TUMT group and highest in the ILC group. The cost-effectiveness ratio (C/E) was 763 DKK/point reduction in I-PSS in the control group and 1.200 and 938 in the ILC and TUMT group, respectively. An incremental analysis demonstrated that TUR-P/TUI-P dominated ILC. In a similar comparison of the TUMT and the TUR-P/TUI-P group an incremental ratio of 170 DKK/extra point of reduction in I-PSS was found in the TUR-P/TUI-P group. CONCLUSION: In the short-term TUMT and TUR-P has comparable cost-effectiveness. TUR-P was slightly more effective than TUMT, but the cost was also slightly higher. In our set-up of ILC the short-term cost-effectiveness of ILC was inferior to that of TUR-P. Conclusions should be made with caution, since the follow-up at present is short.

[Transurethral microwave thermotherapy. A therapeutic option for high-risk patients with urinary retention secondary to benign prostatic hyperplasia]. / Transuretral mikrobølgetermoterapi. En behandlingsmulighed hos højrisikopatienter med urinretention sekundaert til benign prostatahyperplasi.

Urinary retention secondary to benign prostatic hyperplasia is considered an absolute indication for surgical treatment of the prostate. Transurethral resection of the prostate is still considered the gold standard in terms of effectiveness. One of several new techniques for treatment of BPH is transurethral microwave thermotherapy (TUMT). Our first experiences with this technique in a group of patients with urinary retention were analysed retrospectively. In the short term 16 of the 25 treated patients were able to void spontaneously with acceptable bladder emptying (64%, 95% CI: 43-85). Later on, three of these initial successes received further treatments for BPH, two had a transurethral resection of the prostate and one was given medical therapy. No serious complication was seen except in one patient who developed a urethrorectal fistula which healed following conservative treatment. The success rate following TUMT was inferior to that of standard transurethral resection, but TUMT seems an acceptable alternative in patients with pronounced co-morbidity.

[Transurethral treatment of seminal vesicle abscess]. / Transuretral behandling af vesicula seminalis-absces.

An 83-year old male with a seminal vesicle abscess is presented. Initially, cancer of the prostate was suspected and the findings of the transrectal ultrasound scan were misinterpreted. The diagnosis was made by CT-scan. When drainage failed the patient was treated successfully with transurethral unroofing.

Ureteropyeloscopic tumour treatment.

Ureteropyeloscopy was used to follow-up two patients with upper urinary tract transitional cell tumours treated by topical chemotherapy. Epodyl was instilled into the pelvis and ureter through a ureteric catheter. There were no complications. The ureteric tumours responded completely, whereas a pelvic papilloma diminished in size to about 1 mm.

Ureterorenoscopy. Results of diagnostic and therapeutic procedures.

During a 32-month period, 215 ureterorenoscopies were attempted in 171 ureterorenal units. The success rates for stone retrieval were 87% in the lower third of the ureter, 67% in the middle third, 75% in the upper third, and 55% in the pelvis. In 18% of cases a particular lesion could not be reached in diagnostic endoscopy but biopsies were obtained from seven out of eight tumours. The ureteric orifice was never dilated beyond 8 F and, yet, only four times could the instrument not be passed into the ureter. One major complication, an avulsion of 12 cm of the distal ureter, occurred. It is concluded that ureterorenoscopy is of significant value in the diagnosis and treatment of ureteric diseases.

The significance of uninhibited detrusor contractions in prostatism.

In an attempt to identify preoperatively patients who will not benefit from prostatectomy, 84 patients with prostatism about to undergo transurethral resection of the prostate were evaluated prospectively with preoperative and postoperative symptom analysis and urodynamic examination, including cystometrograms. Of the patients 67 were followed at 3 months and 54 again at 12 months. Preoperatively, 65 per cent of the patients had uninhibited detrusor contractions, while 38 had persistent postoperative uninhibited detrusor contractions at 3 months. Patients in whom uninhibited detrusor contractions persisted postoperatively more often had unacceptable postoperative symptoms. Of the patients 13 per cent believed the symptoms to be the same or worse at 3 and 12 months. The incidence of uninhibited detrusor contractions in these patients was 57 and 71 per cent, respectively. While this finding suggests that persistent postoperative uninhibited detrusor contractions are associated with an unfavorable surgical outcome, we could not predict which patients would have uninhibited detrusor contractions following prostatectomy by use of preoperative cystometric findings together with detailed symptom analysis. Thus, we failed to define a role for preoperative cystometric screening of patients with prostatism.

Early surgical intervention in non-specific pleural empyema.

During a 4-year period, 18 patients were treated for non-specific pleural empyema. Nine patients were treated by closed intercostal drainage and 9 by early decortication. The length of time from initial treatment until complete resolution of the empyema and healing of the wound was compared between the groups and highly favored early surgery. We conclude that if an empyema does not show signs of regression after one week of drainage, surgical intervention is indicated.

Amifloxacin distribution in the dog prostate.

Constant infusion experiments with amifloxacin, a quinoline carboxylic acid derivative, were performed in five anesthetized dogs to determine the drug concentrations in prostatic secretion (PS), prostatic interstitial fluid (PIF), prostatic tissue, and plasma (P). The experiments were carried out under steady-state conditions. Amifloxacin concentrations in PS and PIF were lower than the corresponding P concentrations, as might be expected for an acid compound. There was no significant difference between the PS/P and PIF/P concentration ratios of the drug, and none exceeded 1.0. The concentrations of amifloxacin in PS, PIF, and prostatic tissue were above the minimal inhibitory concentration values of most gram-positive bacteria causing chronic bacterial prostatitis. Clinical trials of amifloxacin seem justified.

Candicidin in treatment of benign prostatic hypertrophy.

In a prospective, double-blind, placebo-controlled multicenter study, candicidin (a polyene macrolide) was investigated in the treatment of benign prostatic hypertrophy. Seventy-six patients were included in the study--34 in the candicidin group and 42 in the placebo group. Patients treated with 270 mg. of candicidin daily for 6 months had a significant decrease in residual urine, voided volume and bladder volume. No significant increases were found in flow rates. Symptoms improved significantly in both the candicidin and the placebo group, but no differences in improvement were found between the groups. The results of candicidin treatment are less satisfactory than those following surgery.

Analysis of presenting symptoms in prostatism.

A prospective evaluation was done of 84 patients who were selected for transurethral prostatectomy based on the presenting symptoms and findings at cystoscopy. In addition, urodynamic studies were performed but the results were not made available to the urologist who selected the patients for surgery. Postoperative symptom analysis and repeat urodynamic examinations were done at 3 months in 68 patients and at 12 months in 50. There was no significant association between irritative symptoms and uninhibited detrusor contractions. Furthermore, no associations were identified between obstructive symptoms and infravesical obstruction as defined by urodynamic criteria. The study failed to identify a need for routine invasive urodynamic investigation of patients with benign prostatic hypertrophy.

Transurethral prostatic resection with suprapubic trocar technique.

The use of a suprapubic trocar in transurethral prostatic resection was evaluated between 1975 and 1982. Of 884 transurethral prostatic resections performed 577 were done using the trocar, and 307 using the conventional filling and emptying technique. There was no difference in operative time when resecting small glands. All large glands (more than 30 gm.) were resected using the trocar technique. Severe cases of the so-called transurethral resection syndrome have been eliminated completely by this procedure. The blood loss was slightly higher when the trocar technique was used, probably because of the low pressure in the prostatic fossa during resection. We recommend the trocar in transurethral prostatic resection, since it facilitates the procedure by allowing uninterrupted resection, keeps the bladder pressure low and, thereby, minimizing the amount of absorbed irrigating fluid, and has practically no complications.

Persistent bladder dysfunction after surgical and combination therapy of cancer of the cervix uteri stages Ib and IIa.

The present study is a urologic follow-up investigation of 27 women 17 to 32 months after treatment for carcinoma of the cervix stage Ib and IIa. In 10 women treatment had been exclusively with surgery, while 17 women had received treatment with cesium before surgery. Two patients had major urologic problems with severe stress incontinence and persistent bladder infection, respectively, while 19 had minor urologic complaints on questioning. Nine of twenty-two women (41%) subjected to denervation supersensitivity tests had positive tests. No correlation between a positive denervation test and urologic complaints or findings at cystometrograms could be found. No differences in urologic complaints or results of denervation tests and cystometrograms were found between women treated with surgery exclusively or with cesium before surgery. All treated women had unimpaired renal function judged by serum creatinine and isotopic renography.

Distribution of ciprofloxacin in the dog prostate and various tissues.

The distribution in the dog prostate and other tissues of ciprofloxacin, a quinoline carboxylic acid derivative, was investigated in an experimental model. The concentrations in prostatic tissue, prostatic interstitial fluid (PIF), and prostatic secretion (PS) were lower than the corresponding plasma (P) concentrations, as would be expected for an acidic compound. The experiments were carried out under steady state conditions during intravenous infusion in one group of dogs and following gastric administration in another group. During steady state the ciprofloxacin concentrations were significantly higher in PS than in PIF, and the median PS/P ratios were significantly higher than the PIF/P ratios. These concentrations and ratios were compared with those of two other quinoline carboxylic acid derivatives, rosoxacin and norfloxacin. The concentrations of ciprofloxacin in prostatic tissue, PIF, PS, and urine were several times higher than the minimum inhibitory concentrations for most gram-negative pathogens that cause bacterial prostatitis and urinary tract infections. Clinical trials of ciprofloxacin in these diseases are therefore indicated.

Ceftazidime, a new cephalosporin in the treatment of complicated urinary tract infections: a comparative study with tobramycin.

Ceftazidime is a new synthetic cephalosporin stable to beta-lactamase. In an open prospective randomized study, the safety and efficacy of ceftazidime was compared to that of tobramycin. Fifty-one patients were treated with either ceftazidime (0.5 gm. intramuscularly every 12 hours) or tobramycin (1 mg. per kg. intramuscularly every 8 hours) for 7 to 10 days. Four patients were excluded from each treatment group, leaving 22 patients in the ceftazidime group and 21 in the tobramycin group. The groups were comparable in age, weight, underlying disorders of the urinary tract and distribution of bacteria. Cure was defined as sterile urine 7 to 10 days after treatment. The cure rate for ceftazidime was 73 per cent and for tobramycin, 62 per cent (0.6 less than p less than 0.7, chi-square test with Yates correction). Both drugs were well tolerated, but serum glutamic oxaloacetic transaminase rose in the tobramycin group. No patients had nephrotoxic reactions. We conclude that ceftazidime is a safe and efficient treatment of complicated urinary tract infections.