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BPH MANAGEMENT MINIMALLY INVASIVE AND ENDOSCOPIC TECHNIQUES.

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Presentation on theme: "BPH MANAGEMENT MINIMALLY INVASIVE AND ENDOSCOPIC TECHNIQUES."— Presentation transcript:

1 BPH MANAGEMENT MINIMALLY INVASIVE AND ENDOSCOPIC TECHNIQUES

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8 BPH Minimally Invasive Rx Options Urethral stentsUrethral stents TUNATUNA Microwave thermotherapy- TUMTMicrowave thermotherapy- TUMT Laser TherapyLaser Therapy HydrothermotherapyHydrothermotherapy

9 Indications for Invasive Therapy for BPH Failure of medical therapyFailure of medical therapy Urinary retention->1/3 bladder vol.Urinary retention->1/3 bladder vol. Recurrent urinary infectionRecurrent urinary infection VesicolithiasisVesicolithiasis Recurrent hematuria- grossRecurrent hematuria- gross AzotemiaAzotemia

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11 Criteria for Utilization of Alternative Minimally Invasive Therapies Less adverse side-effectsLess adverse side-effects Approaches or = surgical outcomesApproaches or = surgical outcomes No AnesthesiaNo Anesthesia Shorter Hospital stayShorter Hospital stay Less expensiveLess expensive Safety profile = /> surgical therapySafety profile = /> surgical therapy

12 Treatment Options- Minimally Invasive Therapies Advantages Less adverse effects Less adverse effects No anesthesia No anesthesia No hospital stay No hospital stay Cheaper Cheaper Approaches outcomes of surgery Approaches outcomes of surgery Disadvantages Less favorable outcome, flow & sx’s Retreatment Cost $ & suffering of retreatment Complications- hematuria, dysuria, retention

13 Urethral Stents Initially conceived to relieve BOO 2º to BPH *, later to urethral strictureInitially conceived to relieve BOO 2º to BPH *, later to urethral stricture Types-Types- 1. Temporary 2. Permanent Endoscopic insertion Endoscopic insertion Major role in patients unfit for surgery Major role in patients unfit for surgery *Fabian,1980

14 Urethral Stent- Temporary NonabsorbableNonabsorbable removed or changed q6-36 mos. topical with sedation success 50-90% no catheter or cysto with stent in situ complications-encrustation,migration, breakage,stress incont. UTI, hematuria

15 Urethral Stent-Temporary Intraurethral Catheter(polyurethrane)Intraurethral Catheter(polyurethrane) –de Pezzer proximal end(like a malecot) –may used after TUMT –16 Fr,variable to single lengths –Nissenkorn, Barnes, Trestle(two components) –Usually left for 1 month –Complications- hematuria, urinary retention, –Await large multicenter RCT

16 Urethral Stent- Biodegradable Polyglycolic acid reinforcedPolyglycolic acid reinforced Placed after laser prostatectomy,TUMTPlaced after laser prostatectomy,TUMT Voiding difficulty at 3-4 wks, transientVoiding difficulty at 3-4 wks, transient Cost-effectiveness questioned,added toCost-effectiveness questioned,added to TULP or TUMT Await long term, multi-center RCT Await long term, multi-center RCT

17 Urethral Stent-Permanent Attempt to permanently, definitivelyAttempt to permanently, definitively treat BOO 2º BPH treat BOO 2º BPH Initial enthusiasm turned to present Initial enthusiasm turned to present literature silence Initially introduced to Rx USD Initially introduced to Rx USD Present use-USD,S-D dyssyner., post- brachytherapy, Present use-USD,S-D dyssyner., post- brachytherapy,

18 Urethral Stent- Urolume Manufactured by AMS, for BPH patientsManufactured by AMS, for BPH patients Modified both stent and delivery deviceModified both stent and delivery device Lengths vary from 1.5 –4.0 cmLengths vary from 1.5 –4.0 cm Symptoms scores improve 8-9 pts.Symptoms scores improve 8-9 pts. Flow rates improve 4-6cc/sec(peak)Flow rates improve 4-6cc/sec(peak) Used in nonsurgical candidatesUsed in nonsurgical candidates Interest has waned with Tuna and TUMTInterest has waned with Tuna and TUMT

19 Urethral Stent- Urolume ComplicationsComplications epithelial hyperplasia migration of stent irritative voiding painful ejaculation

20 Urethral Stent- Others Memotherm- variable resultsMemotherm- variable results ASI –withdrawn from productionASI –withdrawn from production Ultraflex-43 fr, 2-6cm, nickel-titanium alloy, used in BPH, D-S dysyner., epithelial hypperplasia and migration lowUltraflex-43 fr, 2-6cm, nickel-titanium alloy, used in BPH, D-S dysyner., epithelial hypperplasia and migration low Conclusion- temporary stents are attractive after TUNA and TUMTConclusion- temporary stents are attractive after TUNA and TUMT

21 Transurethral Needle Ablation of the Prostate Heat delivery system to induce necrosis of the prostate tissue to relieve BOO 2º BPHHeat delivery system to induce necrosis of the prostate tissue to relieve BOO 2º BPH Aim to prostate temp >60º CAim to prostate temp >60º C Uses low-level radio frequency energy delivered by needles into prostateUses low-level radio frequency energy delivered by needles into prostate Use of topical anesthesia adequateUse of topical anesthesia adequate

22 TUNA- Delivery of RF Energy Produced by Vidamed, uses applicator with two needlesProduced by Vidamed, uses applicator with two needles Generator produces monopolar RF signal of 490kHz to give excellent tissue penetrationGenerator produces monopolar RF signal of 490kHz to give excellent tissue penetration Grounding pad over sacrum large sizeGrounding pad over sacrum large size Size of prostate lesion f: kHz,time,depth and position of needle insertionSize of prostate lesion f: kHz,time,depth and position of needle insertion

23 TUNA- Energy Characteristics RF produces molecular agitationRF produces molecular agitation generated heat Heat generated p: 1/radius Heat generated p: 1/radius Heat lost by convection, vascularity Heat lost by convection, vascularity affects lesion size as RF has no effect on vessels > 2-3mm diameter RF hotter central area and quick decline of temp as distance from needles RF hotter central area and quick decline of temp as distance from needles 4

24 TUNA- Experimental Data TUNA creates 1cm necrotic lesion with no damage to rectum, bladder base, or distal prostatic urethraTUNA creates 1cm necrotic lesion with no damage to rectum, bladder base, or distal prostatic urethra Necrosis 7 days, fibrosis by 15 daysNecrosis 7 days, fibrosis by 15 days Treated areas have absence of staining of PSA,smooth mus. actin,  -adrenergic nerual 1-2 weeks)Treated areas have absence of staining of PSA,smooth mus. actin,  -adrenergic nerual 1-2 weeks)

25 TUNA-Experimental Data Sequential injury to different types of nerve endings may occur NOS* most vulnerableSequential injury to different types of nerve endings may occur NOS* most vulnerable Central core Temp ºC, edge of zone 50ºCCentral core Temp ºC, edge of zone 50ºC Treatment times of 5-7 min. needed to produce coagulation necrosis in Rx SiteTreatment times of 5-7 min. needed to produce coagulation necrosis in Rx Site *NOS- nitric oxide synthase

26 TUNA-Instruments

27 TUNA-Instruments RF needles deployed Note insulation and bare tips

28 TUNA-Treatment Position- dorsolithotomyPosition- dorsolithotomy Anesthesia-local, sedation, SAB, GenAnesthesia-local, sedation, SAB, Gen Instrument/needle placed with 0º telescopeInstrument/needle placed with 0º telescope Needle deployed/activated-20x10mm lesionNeedle deployed/activated-20x10mm lesion Two lesions/needle deployment-1 pair/3cm, 2 pair/4cm, additional pair/cm urethral length; Rx bilaterallyTwo lesions/needle deployment-1 pair/3cm, 2 pair/4cm, additional pair/cm urethral length; Rx bilaterally RF power for 5min., catheter is optionalRF power for 5min., catheter is optional

29 TUNA-World Experience

30 TUNA-Summary of Data for 546 Patients* mpkFlow increase % mSI decrease % 6ml/sec Summary of world months follow-up

31 TUNA- Adverse Effects Urinary retention-13-42%Urinary retention-13-42% Irritative voiding-40% (1-7days)Irritative voiding-40% (1-7days) UTI-3%UTI-3% Urethral stricture-1.5%Urethral stricture-1.5% Hematuria-33%, mild, short-livedHematuria-33%, mild, short-lived Reoperation-12-14% in 2 yrsReoperation-12-14% in 2 yrs

32 TUNA-Indications BPH/BOOBPH/BOO Lateral lobe enlargementLateral lobe enlargement Prostate volume <60gmsProstate volume <60gms Median lobe not ideal, but can be RxMedian lobe not ideal, but can be Rx Bladder neck hypertrophy not ideal candidateBladder neck hypertrophy not ideal candidate

33 TUMT-Transurethral Microwave Therapy Evaluated for past decadeEvaluated for past decade Widely used, variable urologist attitudeWidely used, variable urologist attitude Evolution from low-energy to high-energyEvolution from low-energy to high-energy Presently most commonly used devices are Prostatron and TargisPresently most commonly used devices are Prostatron and Targis Current methods use either urethral cooling catheter or non-cooling catheterCurrent methods use either urethral cooling catheter or non-cooling catheter

34 TUMT- Method of Action Heat induced hemorrhagic necrosis, sympathetic nerve injury, apoptosisHeat induced hemorrhagic necrosis, sympathetic nerve injury, apoptosis Tissue exposed to 45ºC for 60 min suffered hemorrhagic necrosisTissue exposed to 45ºC for 60 min suffered hemorrhagic necrosis Sympathetic nerve injury histologically confirmed in 2 reports…Sympathetic nerve injury histologically confirmed in 2 reports… Suggests thermal injury to adrenergic fibers likely accounts for symptomsSuggests thermal injury to adrenergic fibers likely accounts for symptoms

35 TUMT-Method of Action Targis antenna( MHz) exceedsTargis antenna( MHz) exceeds Prostatron(1296MHz) in efficiency of delivery of thermal energy  1-adrenoreceptor density after TUMT  1-adrenoreceptor density after TUMT Adrenergic nerve fibers remain in lamina propria and epithelial layers, virtually absent in smooth muscle layers Adrenergic nerve fibers remain in lamina propria and epithelial layers, virtually absent in smooth muscle layers

36 TUMT- Method of Action Apoptosis induced by moderate thermal energy for longer period of timeApoptosis induced by moderate thermal energy for longer period of time Hemorrhagic necrosis induced by higher thermal energy over shorter timeHemorrhagic necrosis induced by higher thermal energy over shorter time Brehmer and Svennson demonstrated poptosis in 76% of cultured prostate cells 24 hrs after heat exposure, only 14% were necroticBrehmer and Svennson demonstrated poptosis in 76% of cultured prostate cells 24 hrs after heat exposure, only 14% were necrotic

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45 Thermatrix vs High Energy, Cooled Microwave ThermoRx TherMatrixTUMT High Power Cooled Rx delivery Urethral Cath energyMicrowave: Avg 6 watts Microwave: watts effectTissueNecrosis Tissue Necrosis tolerance Oral meds only Parental Recommended

46 Thermatrix vs High Energy Microwave, Cooled ThermoRx TherMatrixTUMT High Power Cooled Rx AUA 12m 47% decrease 44-51% decrease 58% decrease 45-55% decrease Side Effects Minor,Self- resolving Significant,long er duration SAE(FDA filed MDRs) None Rectal fistula, penile necrosis

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48 5mm-62.4ºC 10mm-50.5ºC 15mm-temp =urethral Larson and Collins, 1995

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51 TUMT- Clinical Results # of Patients 110Sham 35 pts TUMT 75 pts SxIndex  pFlow  cc/sec cc/sec Blute et al 1996, Three months duration- TUMT vs Sham

52 TUMT- Clinical Results # of Patients 125Sham 44 pts TUMT 79 pts Sx Index  pFlow  cc/sec cc/sec Larson et al 1998 Six Months Duration- TUMT vs Sham

53 TUMT- Clinical Results # of Patients TUMT-31(26)TURP-21(18) Sx Index   pFlow  cc/sec cc/sec Press/Flow(0- 6m) Obstructed 62-40% Obstructed 76-15% Catheter: time 12.7 days(6-35) 4.1 days(4-5) Irritative void 29%19% Twelve Months Duration- Prostatron 2.5 vs Turp D’Ancona et al 24 mos 8/31TUMT & 1/21 needed other Rx

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60 TUMT-Conclusion Symptomatic improvement after TUMT appears to be energy relatedSymptomatic improvement after TUMT appears to be energy related Objective improvement after TUMT may be insignificantObjective improvement after TUMT may be insignificant Symptomatic improvement may be significant without objective improvementSymptomatic improvement may be significant without objective improvement

61 Laser Therapy TypesTypesNeodynium:Yttrium-Aluminum-Garnetwavelength-1064nn Potassium Titanyl Phosphate wavelength-532nn Holmium: Yttrium-Aluminum-Garnet wavelength-2100nn Diode- most energy efficient

62 Laser Therapy Methods of deliveryMethods of delivery End firing, Bare tip, Sculpted tip, Sapphire tip, Side firing, Metal or Glass reflector, Prismatic internal reflector, interstitial, Diffuser tip, Diffuser tip with temperature transducer

63 Laser Theraapy-Method of Action 45-50ºC -tissue desiccation45-50ºC -tissue desiccation ºC - tissue coagulation, irreversible effects50-100ºC - tissue coagulation, irreversible effects 100ºC +- tissue boils, vaporizes, carbonized100ºC +- tissue boils, vaporizes, carbonized

64 Laser Therapy- Summary There is incomplete and insufficient quality data at present in the medical literature to allow statement of the safety and efficacy of Laser prostatectomy.There is incomplete and insufficient quality data at present in the medical literature to allow statement of the safety and efficacy of Laser prostatectomy.

65 Hydrothermotherapy Recent Appliance availabliltyRecent Appliance availablilty Recent Application attemptsRecent Application attempts Insufficient Outcome Evidence to permit definitive statement of safety or efficacyInsufficient Outcome Evidence to permit definitive statement of safety or efficacy

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71 Office-Based Transurethral Microwave Thermotherapy for BPH Using TheraMatrix TMx-2000 Results of Multi-Center, Prospective, Randomized, Sham-Controlled Study

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