Thursday, 05 November 2009

Division of Urology, University of Texas Medical School at Houston, Houston, TX, USA.

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Benign prostatic hyperplasia (BPH) is a chronic and often progressive condition, affecting the majority of men by the seventh decade of life. The historical gold standard has been transurethral resection of prostate (TURP), an effective procedure still associated with risk of bleeding, TUR syndrome, and need for general anesthetic and hospitalization. Minimally Invasive Surgical Techniques aim to address these limitations by offering lower morbidity, reducing hospitalization, and increasing convenience. These therapies include transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), laser resection/ablation therapies, transurethral ethanel ablation of prostate (TEAP), and high intensity frequency ultrasound (HIFU). A PubMed search was conducted using the keywords ''benign prostatic hyperplasia'' and ''minimally invasive surgery''. Additionally, searches involving the specific procedures (e.g. ''transurethral microwave thermotherapy'' or ''TUMT'') were performed. Relevant English articles were reviewed and synthesized. Randomized, comparative trials between TUMT versus TURP show symptom scores to be comparable, though flow rates were clearly superior for TURP. Similar findings were seen in studies between TUNA and TURP, though the follow-ups times were shorter. Laser therapies vary by characteristic wave-lengths, delivery systems, and techniques used. They all possess excellent safety and hemostatic profile, with the use of Holmium laser well studied in anticoagulated patients. The levels of efficacy vary, with Holmium the most established at providing comparable results to TURP in IPSS and flow rates, while having lowing complication rates. Fewer randomized trials with KTP versus TURP exist, and show divergent results and more trials with longer follow-up are needed. TEAP shows promising results, though several severe morbities have been reported. HIFU remains mostly experimental though feasible, with very few studies conducted. The MISTs offer certain advantages over traditional TURP, including improved hemostasis and the convenience/savings of shorter hospitalization or availability of office procedures. This must be tempered with the various shortcomings of the MISTs, including higher rates of reoperations for the office based procedures of TUMT and TUNA, lower flow rates, and less established