Laser Prostatectomy
Laser prostatectomy is performed with the use of a laser with various types and wavelengths have the advantages of lack or decreased risk of complications such as intraoperative bleeding and fluid absorption, retrograde ejaculation, impotence, and incontinence. Patients undergoing this procedure tend to require shorter hospital stays and can be admitted on an outpatient basis. Four general techniques include:
- Non-contact visual laser ablation of the prostate (VLAP)
- Interstitial laser coagulation of the prostate (ILC)
- Transurethral laser enucleation prostatectomy
- Transurethral laser vaporization of the prostate
- Transurethral laser photo selective vaporization of the prostate (PVP)
The advantages and disadvantages of these procedures vary with each technique and can include lengthy operative times, higher incidence of postoperative urinary retention, prolonged catheterization, and increased irritative voiding symptoms and urge incontinence. Efficacy is generally less than that seen in TURP and can be technically simple to challenging. Until recently, most laser techniques were rarely used. However, the technology is constantly evolving. ILC is a minimally invasive thermotherapy is currently utilized in an outpatient to office setting. PVP is a new laser technology that promises to be as effective as TURP with less complications.
Transurethral Microwave Thermotherapy (TUMT)
Transurethral thermotherapy (microwave hyperthermia) uses microwave energy with frequencies between 915 and 2450 MHz to heat tissues through radiant heat transfer. Using a probe transurethrally (also transrectally), microwave heat delivery is maximized to the prostatic tissue (to a temperature of 42 to 45 C) while the surrounding tissue is cooled by a special catheter in certain devices. This procedure can be performed as an outpatient procedure with local anesthesia. Although it is safer than TURP, it is not as effective. Reported results involve a 67% reduction of symptoms with a 42% increase in urinary flow rate at 1 year. Retreatment is necessary in 1 % to 13 % and recatheterization rates are as high as 40%. Side effects include bleeding, bladder spasms, and blood in the ejaculate.
High Intensity Focused Ultrasound (HIFU)
High intensity focused ultrasound uses ultrasonic energy (transrectally) to heat the prostate without causing damage to tissue lying in the path of the ultrasonic beam. In one study: following treatment, symptom scores decreased from 31 to 16 and flow rates increased by a mean of 5 ml/sec. However, these are only short-term results (90 days). Most common complications include transient urinary retention (73%) and blood in the ejaculate (47%). This therapy is still investigational in the United States.
Transurethral Needle Ablation (TUNA)
Transurethral needle ablation (TUNA) uses high-frequency radio waves to cause thermal injury to the prostate (above 100 ? C). Needles deliver the energy to a localized area of the prostate. In one study, one year following treatment, symptom score decreased from 21 to 10 and flow rates increased from 8 ml/sec to 15 ml/sec. It is fast, usually requires only local anesthesia, and can be done on an outpatient basis (sometimes without the need for a catheter). Complications include urinary retention, blood in the urine, and irritative voiding symptoms. The long-term efficacy of this procedure has not been determined.
Prostatic Stents
Prostatic stents are permanent, flexible, self-expanding devices placed in the urethra to maintain patency of the lumen. Improvement in symptoms and flow rate approach those of TURP, although randomized trials need to be performed. One study showed an decrease in symptom score from 14 to 5 and increase in flow rates from 1 ml/sec to 13 ml/sec with a follow-up of 24 months. Other advantages include: short operative time under regional anesthesia, minimal bleeding, no need for indwelling catheter postoperatively, and performed on an outpatient basis. Many patients experience irritative voiding symptoms following the procedure.
Transurethral Electrovaporization
Transurethral electrovaporization simultaneously vaporizes and coagulates prostatic tissue so no bleeding or fluid absorption occurs. First introduced into the urologic community in 1995, there have been many studies demonstrating similar efficacy, increased safety, and decreased side effects compared to the standard TURP. Studies with long-term follow-up over 7 years have demonstrated this to be a durable procedure. It is now utilized by about 40% of the urologic community. Catheters remain for 1 day and patients spend 1 day in the hospital. Though complications similar to TURP can occur, the risk of significant complications such bleeding, salt imbalances from fluid absorption, impotence and incontinence are low.
Prostatic Urethral Lift (PUL)
The UroLift System offers a minimally invasive treatment option for men with benign prostatic hyperplasia (BPH), using small implants to lift and secure enlarged prostate tissue, thereby alleviating obstruction of the urethra without the need for cutting, heating, or tissue removal. This approach is particularly beneficial for patients with relatively small to moderate-sized prostate glands who prefer to avoid daily medications. Clinical studies have demonstrated the safety and efficacy of UroLift in improving urinary flow and relieving BPH symptoms, while preserving sexual function. Common side effects such as temporary blood in the urine, discomfort during urination, increased urgency, and mild pelvic discomfort typically resolve within a few weeks post-procedure.
The procedure involves inserting the UroLift device through the obstructed urethra to access the prostate, where tiny, permanent implants are deployed to lift and hold the enlarged tissue away from the urethra. This mechanical support effectively restores urine flow and allows patients to resume normal activities promptly after treatment. UroLift represents a significant advancement in BPH management, providing men with a durable solution that does not involve ongoing medication use or more invasive surgical procedures.
Optilume
This minimally invasive surgical therapy combines mechanical dilation with concurrent localized delivery of paclitaxel for treating BPH. Mechanical dilation with the proprietary double-lobe balloon technology achieves an anterior commissurotomy (split) releasing the constricting lateral lobes, while the delivery of paclitaxel prevents re-fusion of the lobes and maintains patency during healing.