Urology

New technologies in benign prostatic hyperplasia management

Roberts WW. Curr Opin Urol 2016; 26(3): 254–258

Alternatives to TURP

The current gold-standard therapy for benign prostatic hyperplasia (BPH) is transurethral resection of the prostate (TURP).1 However, recent technological advances have provided alternatives to surgical debulking, potentially reducing the risk and morbidity of BPH treatment.1

In this review article, Dr William Roberts highlights current developments in minimally invasive therapies for BPH and summarises the effectiveness, safety and potential clinical impact of each procedure.1

Knowledge-led innovation

Enhanced understanding of prostate pathophysiology has led to novel opportunities for therapeutic intervention for BPH.1 For example, prostate stiffness and urethral dysfunction have been linked to increased deposition of collagen and myofibroblast activity.1

Currently available minimally invasive procedures such as transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA) have been shown to be less effective than TURP. These ablative therapies trigger the coagulative necrosis of prostate tissue by transurethral energy transfer. In contrast with TURP however, no BPH tissue is mechanically removed.1

There is growing need for effective, minimally invasive, safe therapies for BPH that can be rapidly performed outside the operating theatre.1

Prostatic urethral lift

The prostatic urethral lift procedure improves urinary flow by the insertion of monofilament sutures with anchors to tent open the anterior aspect of the prostatic urethra. This is a relatively quick procedure that does not require electrocautery and can be performed cystoscopically in an office environment with local/oral anaesthesia.1

Results from the recent 3-year Luminal Improvement Following Prostatic Tissue Approximation study showed improvement in International Prostate Symptom Score (IPSS), quality of life and maximum urinary flow rate (Q_max) following prostatic urethral lift in patients with BPH. Overall, prostatic urethral lift treatment was less effective than TURP, but may be suitable for patients with high surgical risk.1

Convective water vapour

Direct application of high-temperature steam forms the basis of the convective water vapour (CWV) procedure for thermal ablation of prostate tissue. Using a modified cystoscope, an 18-gauge needle is inserted through the urethral wall and steam is delivered to the prostate in 9-second bursts, resulting in local tissue destruction. CWV can be performed with local anaesthesia and oral sedation, and takes an average of 5.3 minutes to complete.1

Results from the Rezum II trial showed improvements in IPSS at 3 months and 1 year post-treatment in patients receiving CWV therapy compared with sham controls. Early indications suggest that CWV-mediated prostate ablation may be more robust than that of TUNA or TUMT.1

Prostate artery embolisation

The occlusion of prostatic arteries provides a means to induce local tissue ischaemia. In prostate artery embolisation (PAE), the arterial vasculature is accessed by femoral puncture and embolisation is performed under local anaesthesia by an interventional radiologist. Ischaemia-associated side effects such as urethral burning, pelvic pain and urinary tract infection have been reported.1

A modified PAE procedure, in which proximal embolisation is followed by distal prostatic artery embolisation (PErFecTED technique), was shown to improve 12-month outcomes compared with PAE in a recent clinical trial.1

Waterjet ablation

Aquablation utilises a high-pressure saline beam applied using a modified cystoscope using transrectal ultrasound targeting to remove anterior and lateral prostate tissue. Recent data from a non-randomised clinical trial showed improvements in IPSS and Q_max 6 months after treatment. Mechanical ablation methods such as waterjet ablation preferentially target glandular components of the prostate, meaning that incontinence and retrograde ejaculation may be less frequently observed compared with other ablation methods.1

Histotripsy

Histotripsy is an extracorporeal ultrasound-based technique for the targeted destruction of prostate tissue. Real-time ultrasound imaging is used to guide the delivery of a cavitation bubble at the focal point of a transducer. In a non-randomised pilot trial, IPSS and quality of life were improved 6 months after histotripsy, but no changes were observed in Q_max, post-void residual volume or prostate volume.1

Conclusions

In conclusion, the author emphasised the importance of further randomised trials to evaluate fully the potential impact of these promising therapeutic developments. It is possible that these technologies may alter the paradigm of BPH treatment.1

Report on: New technologies in benign prostatic hyperplasia management. Roberts WW. Curr Opin Urol 2016; 26(3): 254–258.