Introduction

One of the most common urological issues affecting aging men is benign prostatic hyperplasia (BPH). About 80% of men will develop BPH and nearly one-third of all men will receive surgical treatment [1].

The surgical options for the treatment of moderate to severe bladder outflow obstruction (BOO) have evolved over the past decade. Standard surgical options include transurethral resection of the prostate (TURP) and open prostatectomy, i.e. adenoma enucleation through a suprapubic transvesical (Freyer) or retropubic approach (Millin). While TURP remains an effective treatment, 15–20% of patients develop a significant complication, and 10–15% require a second intervention within 10 years [2,3].

Although newer and less invasive techniques have been popularized, these should be compared with the standard surgical options, for which the rate of complication is low and long-term success in ameliorating symptoms and improving voiding function has been proven [4]. Nonetheless, for some patients, TURP and open prostatectomy is not a suitable form of treatment, because the patients are either poor surgical risks or are reluctant to undergo an invasive surgical procedure.

This chapter aims to critically appraise the alternatives to TURP and to evaluate the robustness of the evidence supporting these alternatives.

Literature search

A literature search was performed using PubMed (www.ncbi.nlm.nih.gow/pubmed/) with the following keywords: “minimally invasive,” “prostatectomy,” “transurethral microwave therapy,” “needle ablation.” Particular attention was paid to high-quality papers, i.e. systematic reviews, meta-analyses and randomized controlled trials.

Background

Transurethral resection of the prostate is the most widely performed surgery for BPH. However, it requires anesthesia and hospitalization and is associated with short- and long-term morbidity approaching 20%. It is, therefore, no surprise that the search for minimally invasive alternatives rages on. A number of techniques and procedures utilizing myriad technologies, including microwave, radiofrequency energy and lasers, have been approved by the FDA for the treatment of BPH. How do they stack up against TURP? Laser treatment (HoLEP and KTP PVP) are discussed separately. Here we present the evidence for transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA). Other emerging treatments including water-induced thermotherapy and transrectal high-intensity focused ultrasound are not discussed because of the absence of high-quality data. Until these treatments are measured against standard treatment, their use should be confined to trials and remain investigational [5].

The evidence

Transurethral microwave therapy

Transurethral microwave therapy involves the insertion of a specially designed urinary catheter into the bladder, allowing a microwave antenna to be positioned within the prostate. It then heats and destroys prostate tissue. Hoffman and colleagues conducted a systematic review of TUMT versus TURP for the treatment of BPH [6] and updated this with a further systematic review of all randomized controlled trials evaluating TUMT [7]. Six studies were identified comparing TUMT with TURP. The decrease in pooled mean urinary symptom scores favored TURP, as did the increase in pooled mean peak urinary flow. The mean length of hospitalization was 0 days for patients who had TUMT and 4 days for patients who had TURP. However, the mean length of catheterization was 13.7 days for patients who had TUMT versus 3.6 days for patients who had TURP [8]. Dysuria and urinary retention were more common in the TUMT group. There was a significantly lower incidence of retrograde ejaculation, hematuria, blood transfusions and TUR syndrome with TUMT compared with TURP [8–10]. The retreatment rate for TUMT was 19.8–29.3% and related to failure of treatment with mean follow-up of 30–60 months [5] Where retreatment after TURP was sought, it related more commonly to meatal, urethral or bladder neck strictures (9.6% for TURP versus 0.7% for TUMT) [9,11].

Transurethral needle ablation

Transurethral needle ablation involves the delivery of low-level radiofrequency energy to the prostate by placing two needles transurethrally into the prostate. The needles are deployed under direct vision using an endoscope.

Two meta-analyses of trials of TUNA provide robust evidence on its efficacy and safety [12,13]. TUNA was comparable to TURP for symptom score improvement at 3 months, but from 1 year to 4 years, the symptom score improvement favored TURP considerably. Interestingly, at 5 years, the symptom score improvement for TUNA and TURP was identical [12]. TURP outperformed TUNA for improvement in maximum flow rate (Qmax) throughout all time points: at 3 months, the improvement in Qmax for TUNA was 4.85 mL/s (57%) and for TURP 11.37 mL/s (148%). At 5 years, the improvement for TUNA was 2.6 mL/s (30%) and for TURP was 9.8 mL/s (127%) [12] TUNA fared better than TURP for adverse events – the only adverse events which were higher in patients who had TUNA were dysuria and transient urinary retention [12]. The vast majority of patients underwent TUNA as a day case and had the procedure performed with local anesthetic with or without sedation. The retreatment rate for patients who had TUNA was 10% compared with just 1% for TURP [12].

Bouza and colleagues concluded that when comparing TUNA with TURP, TUNA achieves a similar level of efficacy, especially in symptoms and quality of life scores in the short term, but in the medium and long term, TURP proved superior to TUNA in all efficacy measures. However, TUNA was significantly better in almost all safety parameters.

Comment

Transurethral microwave therapy is performed without the need for anesthesia and has a low morbidity rate, making it an attractive alternative to TURP, especially suited to patients who would be considered a high operative risk. However, the retreatment rate is higher for TUMT and the outcome measures are less favorable compared to TURP.

While TUNA does not reach the same level of efficacy as TURP, it can provide adequate short-term symptom relief and improvement in quality of life with low postoperative morbidity. Because TUNA can be performed without a spinal or general anesthetic, it may be an attractive option for selected patients, especially those with considerable anesthetic risk. The potential advantages of TUNA in symptomatic BPH must be balanced against its high rate of retreatment, which represents a substantial limitation. While it will not replace TURP as the gold standard, the available data show TUNA to be an effective and safe minimally invasive procedure for patients who are high risk for surgery or who are keen to avoid the adverse effects of TURP.

In summary, the advantages of TUMT and TUNA are that they are day-case procedures and have a lower rate of side effects and complications. The disadvantages are that they are associated with longer postoperative catheterization period and have a higher retreatment rate. The advantages of TURP are shorter postoperative catheterization period, better and more robust subjective and objective outcome and lower retreatment rate. Disadvantages are that it is an inpatient procedure with longer hospital stay and a higher side effect and complication rate. We conclude that TURP remains the preferred approach for most patients (conditional recommendation for TURP; 2B); however, in high-risk patients, the evidence supports a conditional recommendation for TUMT or TUNA (2B).

Literature search

A literature search was performed using PubMed with the following keywords: “prostatectomy,” “potassium-titanyl-phosphate laser,” “green light laser,” “KTP,” “photoselective laser vaporization,” “holmium laser” and “enucleation.” Systematic reviews, meta-analyses and randomized controlled trials were given particular attention when formulating recommendations.

The evidence

Holmium laser enucleation of the prostate

Laser prostatectomy was pioneered by Chun [14] and Gilling [15] using a combination of holmium and Nd:YAG laser. Not long after this, techniques were developed using holmium laser exclusively. Holmium laser has a wavelength of 2140 nm and is strongly absorbed by water. The depth of thermal damage ranges from 0.5 mm to 1.0 mm, enabling excellent cutting and tissue ablation, but avoids deep coagulative tissue necrosis [16]. It is a pulsed laser which allows precise tissue vaporization at the tip of the laser fiber. It is therefore an excellent incisional tool for soft tissue [17]. Furthermore, it conducts through saline and thereby removes the risk of the TUR syndrome.

Holmium laser enucleation of the prostate involves laser dissection of the median and lateral lobes of the prostate from its capsule. Once the prostate is enucleated, the lobes are morcellated in the bladder prior to removal.

The literature on HoLEP is particularly formidable, with a significant number of randomized controlled trials (RCTs) and a meta-analysis published, providing high levels of evidence.

No less than four RCTs have been published comparing HoLEP with TURP for large prostates causing BOO. Gupta and colleagues published results of their prospective RCT of 50 patients randomized into three equal-numbered groups: TURP, transurethral vaporization of prostate (TUVP) and HoLEP [18]. All patients had BPH and prostate glands greater than 40 g (mean 58–63 g) measured with transabdominal ultrasound. Blood loss, the volume of postoperative irrigant, nursing contact time and catheter duration were all significantly less with HoLEP compared to the other two modalities. However, operative time and volume of operative irrigant were significantly greater for HoLEP. Although complication rates were no different between the three groups, bladder mucosal injury was peculiar to the HoLEP group. The outcome measures of IPSS, maximum flow rate (Qmax) and postvoid residual (PVR) volumes were comparable for the three groups, though the follow-up period was short at only 1 year.

Wilson and colleagues reported their 2-year follow-up of a RCT comparing HoLEP with TURP involving 61 patients in total [19]. Prostate volumes were measured with transrectal ultrasound and the mean volume was 77.8 ± 5.6 g (42–152) in the HoLEP group and 70.0 ± 5.0 g (46–156) in the TURP group. They reference their earlier work that found HoLEP to be superior to TURP as regards catheter time and hospital stay but took significantly longer to perform [20]. At 2 years, there was no significant difference between the two groups with respect to American Urological Association scores, quality of life scores or Qmax values. Two patients from the TURP group required reoperation. The authors concluded that HoLEP was comparable to TURP at 2 years.

Montorsi and colleagues published the first multicenter RCT comparing HoLEP and TURP [21]. One hundred patients were randomized into either HoLEP (52 patients) or TURP (48 patients) and followed for 1 year. While outcome measures and complication rates at 1 year were similar in both groups, patients who had HoLEP had shorter catheterization periods and shorter hospital stays.

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