1. Prostatic Hyperplasia: Evolution of Treatment
Julie M Riley MD

2. Ancient Years
Prostate was originally used in 300 BC but “forgotten” until 1550
1649: Jean Roilan suggested that an enlarged prostate caused retention
Managed with catheters and sounds

3. Punch Techniques
1575: Pare used a punch tip to pass through and clip the prostate
1756 Lafaye passed a lance-shaped stylet through the median lobe
Patient lived for 10 years
Others tried with fatal result
1761:Morgagnidescribed BPH with associated bladder findings on autopsy
Lafaye patient at autopsy had false passage

4. Early Days
1815: Syng used a metal catheter with a balloon on the end to dilate the prostate
Most therapies were ineffective and painful.
Many proved fatal
Held pressure for as long as the patient could tolerate, usually ~15 minutes

5. Adenectomy Started in conjunction with perineal lithotomy
First complete adenectomy was in 1891
With anesthesia and antiseptic techniques, suprapubic approach was favored
1911: Squier performed first suprapubic prostatectomy as performed today

6. Transurethral Surgery
1830: Guthrie used a knife to incise the bladder neck
1873: electrocautery was used to burn after incising
1897: paired with cystoscope, allowed for visual control
1908: Bugbee and others used monopolar current to detroy prostate tissue
1926 Collings used current to cut tissue and the resectoscope was invented by Stern
Davis improved monopolar energy with two currents, one to cut, the other to coagulate

7. Early Days
TURP remained the gold standard of BPH but problems continued
Bloody
Requires cessation of anticoagulation
TURP syndrome
hospitalization

8. Along came the Laser

9. Laser Treatments
TULIP: requires ultrasound rather than direct visualization
Not as effective as traditional TURP
Replaced by newer technology

10. Laser Fibers Nd:YAG: wavelength of 1064 nm
Penetrates deeply, poorly absorbed by water or blood
Tissue becomes white and sloughs after treatment
KTP (Greenlight): wavelength of 532 nm
Half the depth of penetration compared with ND:YAG which causes higher energy per tissue volume
Holmium: 2100 nm
Series of rapid pulses
Vaporizes the tissue water, worse hemostatic properties
Very little tissue penetration
Diode: 980 nm
Absorbs both water and blood
Thulium: 2097 nm
Contiuous wave, allows smoother cutting
Neodynium: Yittrium-Aluminum-garnet laser
Potassium-titanyl-phosphate laser

11. Laser Fibers

12. Nd:YAG laser First widely used laser for prostate
Initially used for vaporization
Significant prolonged LUTS as tissue sloughed
Developed contact tip which allowed for ablation
Not suitable for >40g prostates
Also used for interstitial laser coagulation
High retreatment rates
Similar to vaporization, LUTS and retention common postoperatively
30% had LUTS or retention following vaporization at 3 months

13. KTP laser Originally used with Nd:YAG as hybrid procedure
KTP used to incise bladder neck
Now used independently as green light laser
Have 120 W laser
Performed in noncontact fashion
Allows for immediate relief of symptoms even in very large prostates
With the higher power KTP lasers, ability to coagulate has decreased
Hybrid procedure designed to reduce the rate ofpostop retention and LUTS

14. Diode Laser
Allows for vaporization like 120W KTP laser but better hemostasis like 80W KTP
Higher rate of irritative symptoms and epididymitis

15. Ho:YAG Laser
Ideal laser for vaporization as small absorption depth and ability to coagulate blood vessels
HoLAP was bloodless with minimal char but too slow for large prostates
HoLRP: used end firing laser to remove chips
Slow and technically difficult
HoLEP: simulates open approach
Size no longer an issue

16. Thulium Laser Used similarly to Holmium laser
Better vaporization ability leads to smooth incisions
Better visualization of planes

17. Refinements to the TURP

18. Complications
Mortality rate significantly declined from 5% in 1976 to 0.2% in 1989
More contemporary studies find mortality rate similar to those on observation of BPH
Complications were as high as 18% in 1989 but more recently describes as 9%
Included retention (4%), perforation of capsule (2%), transfusion (1%)
Best longterm outcomes in men with bothersome symptoms at baseline

19. TURP Refinements
Continuing morbidity lead to development of bipolar TURP (Gyrus)
Allows use of saline essentially eliminating TUR syndrome
Early studies demonstrate earlier discharge and earlier removal of catheter
Decreased clot retention
Comes in loop and button

20. Other Technologies

21. Transurethral Needle Ablation
Low level radiofrequency energy
Increase temperature >60C to induce necrosis
Can be down under local anesthesia
Creates 1 cm necrotic lesions without damage to surrounding tissue
Delivery via catheter inserted under direct vision
Position needles using TRUS
Teflon shield on the catheter to protect the urethra
2 needles can treat ~20 grams
5 minutes of treatment per lesion

22. TUNA Long term results are scarce but still promising
Not quite as good as TURP but see 50% improvement in IPSS and flow rate
Complication rates are low
Retention, irritative voiding symptoms, bleeding, infection, stricture
Best for large lateral lobes, <60 grams
Retention 40% at 24 hours
Irritative symptoms last 1-7 days

23. TUNA

24. Transurethral Microwave Therapy
Heat prostate tissue while simultaneously cooling urethral mucosa
Causes heat induced necrosis, sympathetic nerve degeneration and apoptosis
Not as effective as TURP but less complications
Improved results over sham surgery except in 1 study
Long term data is starting to be accrued

25. TUMT

26. What’s Next Lasers continue to evolve Novel techniques
Erbium is coming
Need more portable, cheaper fibers
Improve irritative symptoms following surgery
Novel techniques
Need a method that can be offered in the office with minimal anesthesia
Needs to be portable and cheap, accessible
Improve retention rates to avoid post op catheters
Erbium is more expensive and delivery method may be toxic