Although prostate transurethral resection (TURP) and laser treatments (PVP, prostate enucleation) are the most common surgical procedures for the treatment of benign prostatic hyperplasia (BPH), other options Non-medicinal products may also be considered. These techniques usually do not remove the adenoma from the prostate but are promoted as being able to reduce the inconvenient effects for the patient and improve its comfort.
The major risk is therefore to overestimate the effect of the technique by a placebo effect, known to be very pronounced with regard to urinary symptoms.
As these techniques are usually not or only slightly superior to medical treatment, these techniques should also not expose the patient to the risk of serious complications.
1. Thermotherapy by transurethral microwaves (TMTU)
Transurethral Microwave Therapy (TMTU) uses microwaves to destroy excess prostate tissue by heat.
“Thermotherapy” means that this treatment uses heat.
Transurethral microwave thermotherapy (TMTU) causes coagulation necrosis by local elevation of intra-prostatic temperature. The treatment probe is introduced by the urethra and positioned by traction on the balloon, which brings the transmitting antenna facing the prostate. The delivery of energy is driven by a computer program. The duration of the treatment is 30 to 60 minutes. The treatment is most often performed under local anesthesia by contact anesthetic, possibly supplemented by oral opiates.
The placement of a vesical probe in postoperative is almost systematic.
The TMTU was evaluated by the High Authority for Health (HAS) in 2006, which judged that the efficiency / safety ratio of this technique is not satisfactory: the efficiency is of the same order as that of TUNA (see next chapter) But there are serious complications (burning of the urethra), which although exceptional are unacceptable with regard to the severity of the pathology treated. These complications are linked to the technical difficulties of the TMTU.
2. Needle Transurethral Ablation (TUNA)
The treatment of BPH by thermotherapy was evaluated by the HAS in February 2006. TUNA (Transuretral needle ablation) is a technique using a monopolar radiofrequency Induces coagulation necrosis by heating using electrodes planted under endoscopic transurethral control in the prostatic zone to be treated.
The current flowing for 3 to 5 minutes results in a local temperature rise of about 100 ° C. within a radius of 0.5 cm around the electrode.
The number of applications of the electrodes depends on the size of the BPH. Most often, a bladder probe is left in place after treatment. This can be done under local anesthesia by contact topotics or by prostatic nerve block, but in an operating theater.
According to the results of the 2006 HAS report, the functional results are roughly equivalent to the medications, somewhat less good than the RTUP, but compared to the latter, radiofrequency thermotherapy would have the advantage of not causing d Retrograde ejaculation and would adapt to ambulatory treatment. The main side effect is urinary retention (estimated risk of 20 to 30%), requiring the placement of bladder catheters.
This technique is reserved for patients who are not responding to medications or who do not wish to use a surgical treatment, whose prostate weighs between 40 and 50 g and whose antero-posterior diameter of the prostate does not exceed 80 mm.
3. Urethral Stents
A urethral stent is a small cylindrical grid spring.
The surgeon inserts it by the penis to position it at the level of the narrowed area of the urethra; It can then relax the stent, thus enlarging the urethral canal to facilitate urination by canceling the pressure exerted by the prostatic tissue on it.
This rapid intervention requires only local or spinal anesthesia, does not involve any blood loss and can be performed as an outpatient.
Urethral stents are most commonly used in elderly patients with significant prostatic hypertrophy accompanied by a relatively degraded general state of health; These patients require surgery which must be the least invasive.
These stents are placed temporarily and palliative and must be changed if their maintenance is necessary.
In addition they can move and migrate into the bladder.
4. Intra-prostatic implants
Approved by the FDA in 2013, the UroLift® device is a novel, minimally invasive technology for the treatment of lower urinary tract symptoms caused by benign prostatic hyperplasia (BPH).
Installed in a transurethral, minimally invasive, outpatient procedure, permanent UroLift implants relieve the obstruction of the prostate and open the urethra directly without cutting, heating or removing prostatic tissue.
A single-blind study comparing the placement of these implants versus fictitious surgery without implants has shown their effectiveness in reducing symptoms related to the lower urinary tract and the significant absence of erectile dysfunction Ejaculation observed as a result of other interventions for the treatment of BPH.
The most commonly reported adverse reactions were hematuria, dysuria, urinary urgency, pelvic pain and urgent urine leakage. Most of the symptoms were of low to moderate severity and were resolved within two to four weeks following the procedure.
5. Botulinum Toxin (Botox)
Already used in the filling of facial wrinkles, botulinum toxin is also being studied in men with BPH. Without showing any real benefit in reducing prostate volume, some studies have shown that botulinum toxin injections can reduce pain and other urinary symptoms and improve quality of life.
In France, in spite of hopes based on small studies on the value of Botox® in benign prostatic hyperplasia, the PROTOX study of 127 patients, funded by a Clinical Research Hospital Program (PHRC) Does not show any additional benefit from intra-prostatic injections of botulinum toxin compared to optimal medical treatment.
Designed to prove non-inferiority of injections compared to medical treatment, the study achieved its goal. But it has not been possible to prove the superiority of this approach either and in these conditions it is not justified to place a risk of prostatitis or even more severe sepsis on one third of the patients in order to obtain a subjective effect of Placebo.
- Embolization of prostate adenoma
A new arrival in the surgical treatment of prostate adenoma: embolization of the prostatic arteries. What do we find in literature? Where is the practice?
Embolization, used as a treatment for urinary symptoms related to benign prostatic hypertrophy, is an innovative technique that is minimally invasive.
The procedure, long and technically difficult, requires to be performed by a radiologist under general anesthesia. Difficulties may be encountered: for example, calcified arteries may render the procedure impossible.
The main risk is the embolization of a collateral artery destined for the rectum or bladder.
Today, embolization remains an experimental technique not validated. In fact, few studies have yet been published. The main focus is on the work of only two teams, Brazilian1 and Portuguese2. Apart from that, literature is not rich on the subject. Therefore, prior to making recommendations, a rigorous assessment is required.
This assessment should make it possible to answer the question of the risks incurred, the functional results obtained and the question of the duration of a possible effect.
Evidence of effectiveness to be established and verified.
- Floratos DL, Kiemeney LA, Rossi C, et al. Long-Term Followup of Randomized Trans-urethral Microwave Thermotherapy Versus Transurethral Prostatic Resection Study. Journal of Urology 2001; 165:1533–38. PMID: 11342912.
- Haute Autorité de Santé (HAS) . Traitement de l’hypertrophie bénigne de la prostate par radiofréquence ou micro-ondes . Rapport février 2006. http://www.has-sante.fr/portail/upload/docs/application/pdf/synthese_tuna-tmtu.pdf
- Hoﬀman RM, Monga M, Elliot SP, et al. Microwave Thermotherapy for Benign Prostatic Hyperplasia. Cochrane Database of Systematic Reviews 2012;(9):CD004135. PMID: 22972068.
- Cornu JN, Desgrandchamps F, De la Taille A, et al. Prospective Short-Term Evalu-ation of Transurethral Needle Ablation Procedure in an Ambulatory Setting. Urology International 2012; 89:451–56. PMID: 23108188.
- Hill B, Belville W, Bruskewitz R, et al. Transurethral Needle Ablation Versus Transurethral Resection of the Prostate for the Treatment of Symptomatic Benign Prostatic Hyperplasia: 5-Year Results of a Prospective, Randomized, Multi-center Clinical Trial. Journal of Urology 2004; 171:2336–40. PMID: 15126816.
- Roehrborn CG, Gange SN, Shore ND, et al. The Prostatic Urethral Lift for the Treat-ment of Lower Urinary Tract Symptoms Associated with Prostate Enlargement Due to Benign Prostatic Hyperplasia: The L.I.F.T. Study. Journal of Urology 2013; 190:2161–67. PMID: 23764081.
- Francisco C. Carnevale, Airton Mota Moreira, Alberto A. Antunes. The “PErFecTED technique”: proximal embolization first, then embolize distal for benign prostatic hyperplasia
Cardiovasc Intervent Radiol. 2014 Dec;37(6):1602-5.
8. Joao Martins Pisco, Hugo Rio Tinto, Luís Campos Pinheiro, Tiago Bilhim, Marisa Duarte, Lúcia Fernandes, José Pereira, António G. Oliveira. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS) secondary to benign hyperplasia: results of short- and mid-term follow-up.
Eur Radiol. 2013 Sep;23(9):2561-72.