Laser Treatments for Benign Prostatic Hyperplasia (BPH), Enlarged Prostate
Interstitial Laser Coagulation
Interstitial laser coagulation is often performed under local anesthesia on an outpatient basis. The Indigo LaserOptic Treatment® System uses a cystoscope through which a fiberoptic probe is directly introduced into the prostate. Heat energy is conducted through the probe for 3 minutes and quickly coagulates the obstructing prostate tissue. The process can be repeated to treat another area in the prostate, as determined by the physician. The procedure lasts approximately 30 to 60 minutes. Symptoms resolve over 6 to 12 weeks, as tissue is absorbed.
After the device is removed, a Foley catheter is inserted to drain urine for several days, until bladder function returns. Blood in the urine is a common side effect of the procedure and resolves within a week or so. Erectile dysfunction (impotence), retrograde ejaculation, and incontinence are rare complications.
Photoselective Vaporization of the Prostate (PVP)
Photoselective vaporization of the prostate (PVP) is a minimally invasive procedure that uses a special high-energy laser (e.g., GreenLight PVP Laser) to vaporize excess prostate tissue and seal the treated area. The procedure is performed on an outpatient basis in a hospital or surgical center and may be performed under local, spinal, or general anesthesia. PVP takes between 10 and 30 minutes to perform, depending on the size of the prostate and patients are usually discharged within a few hours.
The type of laser used in PVP is delivered to the prostate through an endoscope (device that consists of a tube and an optical system) that is inserted into the urethra. The procedure prevents damage to surrounding tissue and minimizes side effects such as pain, blood in the urine (hematuria), and swelling.
Many patients do not require a catheter after PVP, and those who do typically are catheterized for less than 24 hours. Patients are advised to avoid strenuous exercise for 2 weeks following the procedure and can usually resume regular activities the next day. PVP provides immediate and long-lasting results comparable with other minimally invasive procedures.
Holium Laser Ablation of the Prostate (HoLAP)
HoLAP (holmium laser ablation of the prostate) involves using a laser to vaporize obstructive prostatic tissue. The decision whether to use HoLAP or HoLEP (holmium enucleation of the prostate) is based primarily on the size of the prostate. Ablation usually is performed when the prostate is smaller than 60 cc (cubic centimeters).
HoLAP offers many of the same advantages as HoLEP when compared to traditional surgery (e.g., TURP). These potential benefits include a shorter hospital stay, less bleeding and shorter catheterization and recovery times.
Patients who undergo HoLAP usually do not require overnight hospitalization and in most cases, the catheter is removed the same day or the morning following the procedure.
Microwave Treatments for BPH
Cooled ThermoTherapy/TUMT reduces BPH symptoms, preserves sexual function, and provides durable results using the Targis® system or the Prostatron® system. Treatment can be completed within 30 minutes, usually does not require anesthesia, and is performed in a physician's office or an outpatient setting.
In this treatment, a specially designed antenna inside a catheter is inserted into the prostate through the urethra. This antenna is used to direct microwave energy into the prostate to heat and destroy enlarged tissue. During the procedure, cool water is circulated through the catheter to minimize patient discomfort, protect adjacent urethral tissues from excessive temperatures, and reduce the risk for serious side effects.
Medication is often administered to reduce discomfort and help patients relax during the procedure. Many patients are able to read, watch television, or listen to music during treatment and some may experience the following:
- Bladder spasms
- Pressure in the rectum
- Sensation of needing to empty the bladder or have a bowel movement
- Warm or burning sensation in the abdomen or penis
Following treatment, anti-inflammatory medication and antibiotics may be prescribed. Most patients can resume normal activity immediately after treatment. Destroyed prostatic tissue is reabsorbed by the body or discharged in the urine over the course of 6 to 12 weeks and BPH symptoms gradually improve during this time.
Side effects usually resolve without intervention within a few weeks of treatment and include the following:
- Frequent urination
- Pink discharge in the urine or around the catheter
- Soreness in the lower abdomen
- Urethral inflammation and swelling (most patients require catheterization for 2–5 days)
- Urgency (even after removal of the catheter)
An outpatient, microwave-generated heat treatment that destroys excess prostate tissue. CoreTherm uses a transurethral catheter containing a microwave antenna and an intraprostatic probe with three temperature sensors. This system takes into account the fact that different patients have differently sized prostates and different intraprostatic blood flows.
Continuous monitoring of intraprostatic temperatures, intraprostatic blood flow rate, progressive destruction of targeted tissue, and adjustable microwave power enable the physician to tailor treatment to the individual. These data are calculated and displayed in real time on a computer screen throughout the session, which helps the physician determine when to stop treatment.
Before the procedure, the bladder and bowel are emptied, and the patient is given a sedative, local anesthesia, and antibiotics. Urinary retention is a common temporary side effect. A urinary catheter is placed after treatment and removed within a couple of weeks.
TherMatrx® is a minimally invasive procedure performed in a urologist's office that uses heat delivered through a microwave antenna. This outpatient procedure requires local anesthesia. A mild sedative or pain reliever may be given to help the patient relax and make him as comfortable as possible during the procedure.
A urethral catheter containing the microwave antenna is passed through the urethra and prostate gland and is secured by a balloon at the tip of the catheter that passes through the uretheral sphincter. Localized microwave energy is delivered at a temperature high enough to relieve BPH symptoms, including difficult, frequent, or urgent urination. The procedure lasts approximately 1 hour.
Following the procedure, a catheter is inserted to drain urine from the bladder for a few days. Once the catheter is removed, the patient can resume normal activity. Symptoms improve in 4 to 6 weeks. Healing takes 6 weeks to 3 months.
Possible complications include incontinence, pain during urination, and urinary retention. Most complications resolve during the healing period without intervention.
Prolieve Thermodilatation System is a transurethral microwave thermotherapy (TUMT) device that also uses a special balloon catheter to open up (dilate) the urethra, as well as microwave energy to heat and destroy enlarged prostatic tissue. In this procedure, the balloon catheter is filled with warm water. After the temperature of the tissue returns to normal, the urethra remains open. Prolieve™, which takes about 45 minutes, is performed in a physician's office under local anesthesia. In a recent study, about 5% of patients required catheterization following the procedure.
Other Minimally Invasive Treatments
The AquaTherm System uses water-induced thermotherapy (WIT) to destroy obstructive prostatic tissue and reopen the urethra. WIT can be performed in ambulatory surgery, outpatient surgery, or a physician's office. It takes only 45 minutes and does not require general anesthesia.
A catheter made up of four contiguous sectionsthe urinary drainage lumen, the positioning balloon, the treatment balloon, and the insulated shaftis attached to a computer console that heats water to 60° C (140° F). Throughout the procedure, the computer console precisely maintains the water temperature at 60° C, and urine is allowed to pass by means of the urinary drainage lumen.
The urologist inserts the catheter through the urethra and into the bladder. Once the urinary drainage lumen and the positioning balloon reach the bladder, the positioning balloon inflates and secures the catheter. The treatment balloon, resting in the prostatic urethra (located directly below the bladder), inflates and fills with water. Temperature-controlled water circulates through the insulated shaft into the treatment balloon. The catheter conducts heat through the insulated shaft to the prostate gland, raises the temperature of the gland, and destroys the obstructive tissue. Destroyed tissue is either sloughed off or absorbed by the body over time. After 45 minutes of treatment, the catheter is removed.
Following the procedure, a urethral catheter remains in place for approximately 4 to 17 days, or until normal urinary flow is restored. Temporary hematuria, or blood in the urine, is usually present after the procedure, and treatable urinary tract infection or urinary urgency also may occur.
Prostiva RF Therapy
Prostiva RF therapy, previously known as TUNA, may be used to treat symptoms of BPH in patients over the age of 50. RF therapy uses low-level radio frequency (RF) energy to destroy excess prostatic tissue, without damaging the urethra or surrounding healthy tissue. In this procedure, a small probe is inserted into the prostate through the urethra, and two electrodes are used to apply a low level of RF energy, which is directed to specific areas of the prostate to relieve obstruction.
RF therapy is performed in an office or hospital outpatient center and typically does not require general anesthesia. The procedure usually takes less than 1 hour to perform and often relieves BPH symptoms within 2 to 6 weeks.
Most patients are able to resume regular activity in 2448 hours. Catheterization (usually not longer than 3 days) may be necessary following treatment. Side effects, which are usually minor and resolve without intervention during the healing period, include blood in the urine (hematuria), obstruction, discomfort or pain (may be relieved using over-the-counter pain relievers), and urinary tract infection (UTI; may require long-term medication).
Long-term complications (e.g., urinary retention, sexual dysfunction) are unusual and occur less often than following conventional procedures such as TURP.
Transurethral Vaporization of the Prostate (TUVP)
Transurethral vaporization of the prostate (TUVP), also called vaportrode, involves direct application of heat (under 100° F) to the prostate tissue with a grooved roller-bar that vaporizes tissue. The immediate tissue loss leads to quick improvement of symptoms. The procedure takes from 20 to 65 minutes. The catheter is usually removed within 24 hours and most patients go home within 2 days.
High Intensity Focused Ultrasound (HIFU)
High intensity focused ultrasound (HIFU) is currently undergoing clinical trials in the United States. HIFU is a noninvasive treatment that uses precision-focused ultrasound waves to heat and destroy (ablate) targeted prostatic tissue without affecting healthy surrounding tissue. It has been shown to effectively treat BPH as well as localized prostate cancer. The Food and Drug Administration (FDA) has not yet approved this treatment in the United States.
In clinical trials, HIFU is performed on an outpatient basis, under anesthesia. HIFU can be repeated as necessary, and each treatment takes 1–3 hours. Following treatment, a catheter is necessary for about 1 week and most patients are able to resume regular activities within days. Impotence occurs in 1–7% of patients.