eMedicine Specialties > Urology > Benign Prostatic Hypertrophy

Interstitial Laser Coagulation of the Prostate

Stanley A Brosman, MD, Clinical Professor, Department of Urology, University of California at Los Angeles Medical School

Updated: Aug 27, 2009

Introduction

Benign prostatic hyperplasia (BPH) is the most common disorder in men older than 40 years. BPH usually starts to become symptomatic in men aged 50 years and older. Because of the intimate anatomic relationship between the bladder, urethra, and prostate, prostatic growth can alter the physiology and function of these organs and produce a symptom complex known as prostatism. Almost every man expects to have some type of prostate problem during his lifetime. Although no one knows how to prevent BPH, other than with castration or testosterone production elimination, treatment options are available that can effectively and safely ameliorate its symptoms and preserve normal bladder and kidney function.

Benign prostatic hyperplasia. The prostate is located at the apex of the bladder and surrounds the proximal urethra.

Symptoms associated with BPH may include an increase in the frequency of urination, hesitancy in starting the urinary flow, a weaker stream, an increase in nocturia, a sensation of incomplete bladder emptying, and urgency that may be associated with incontinence. These lower urinary tract symptoms (LUTS) may result from bladder outlet obstruction (BOO)¹ or BPH. In addition, they may also be associated with an overactive bladder (OAB) in the absence of obstruction. Differentiating the pathophysiology of LUTS, BOO, and OAB allows for application of the most appropriate therapy.

Benign prostatic hyperplasia (BPH) diagnosis and treatment algorithm.

LUTS may be subdivided into different categories for clinical purposes. LUTS associated with clinical BPH assumes that it is the BPH that is responsible for the symptoms, but this is not always accurate.

When symptoms become troublesome, patients seek medical attention from their primary care physician or urologist. Previously, the only therapies were open surgical procedures (eg, suprapubic prostatectomy, retropubic prostatectomy, perineal prostatectomy, transurethral resection of the prostate [TURP]). Now, various therapeutic alternatives are available, including pharmaceuticals, herbal products, or interventional procedures.

Pharmaceutical therapy consists of alpha-adrenergic blockers, 5-alpha-reductase (5aR) inhibitors, various herbal products such as saw palmetto and Pygeum africanum, and a plethora of new procedures, including microwave thermotherapy, prostate vaporization techniques, free-beam laser prostatectomies, thermotherapy with heated water, photodynamic therapy, injection therapy with alcohol, high-intensity focused ultrasound, and interstitial laser coagulation (ILC).

This article focuses primarily on one of the laser therapies, ILC of the prostate, although the other forms of intervention are discussed.

In the 1980s, several investigators began studying the application of interstitial laser energy to treat various neoplasms. The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser energy was transmitted through flexible end-firing fibers inserted directly into the tumor. This produced a focal area of tissue necrosis surrounding the fiber tip. Small tumors could be effectively eradicated.

In 1991, Hofstetter suggested the use of this technique to treat BPH. Studies in animal and human prostates demonstrated the feasibility of this approach and led to clinical trials for men with symptomatic BPH. The original end-firing Nd:YAG laser fibers emitted a high-energy beam from its tip but produced only a small spherical volume of tissue destruction.

Early fibers were fragile and had a tendency to break during insertion. Recognizing the potential usefulness of this procedure, new fibers were specially designed for treating the prostate. These sturdy fibers were larger in diameter and had pointed tips to facilitate placement into prostatic tissue.

Currently, the fibers have distal-diffusing tips that radiate 360° laser-light energy along the terminal 3 mm of the fiber. During the 90-second or 3-minute laser application time (depending on which model unit is used), ellipsoid volumes of tissue coagulation are created, which surround the axis of the fiber. The affected tissue area has a diameter of 1.5-2 cm and a length of 2 cm, which corresponds to the length of the energy-diffusing fiber tip.

The laser systems, manufactured by Johnson and Johnson (Indigo), in Cincinnati, and Dornier (Fiber Tome), in Germany, are compact, readily transportable, low-power, diode laser devices that use a 15- to 20-watt variable power source. This process produces a wavelength of 800-850 nm. The current indigo system uses an 830-nm fiber, and laser energy transmits through a sterile fiber enclosed within a 2-cm long, high-temperature resistant, light-diffusing tip that fits through a cystoscope. Low-power settings minimize tissue charring, which impedes light and heat conduction and decreases the amount of tissue coagulation.

The transurethral endoscopically guided technique is preferred; however, both transperineal and transrectal approaches are used. Although transrectal ultrasonography was initially used to guide the placement of the fibers, this is rarely necessary. These laser systems (ie, transperineal, transrectal) represent an effective and safe method for relieving BPH-associated symptoms.

History of the Procedure

Although BPH is one of the most common processes in aging males, much remains to be learned about its etiology and pathophysiology. Until 10 years ago, the prevailing opinion was that the symptoms associated with BPH were due entirely to an increase in urethral resistance caused by an enlarged prostate constricting the urethra; however, since that time, obstruction has been noted to produce neurologic alterations in the bladder and prostate, which account for many of the symptoms.

The following terms describe BPH, but no uniform acceptance of any terminology exists. Regardless of which term is used, the patient seeks the attention of a urologist when symptoms of difficult urination begin.

• Prostatic enlargement
• Histologic hyperplasia
• LUTS
• BOO
• Urodynamic obstruction and other appellations

ILC is one of many minimally invasive procedures that have been introduced to alleviate the problems associated with BPH. At this time, stating that one form of therapy is distinctly advantageous over the others is not possible because few comparative studies have been performed. ILC is applicable for prostates smaller than 60 mL in volume, and this procedure, like the others, can be performed in the office with local anesthesia.

Problem

The prostate undergoes significant growth during specific periods (ie, fetal development, puberty, late middle age). At the end of puberty, the prostate size is 15-25 g, and it remains in this range until BPH develops.

Growth of BPH usually begins in men aged 30-35 years. In men aged 30-50 years, the estimated doubling time for prostate weight is 4.5 years. In men aged 50-70 years, the doubling time is 10 years. Researchers postulate that the average age-related growth rate is approximately 6 g per decade.

BPH is the most common tumor that develops in men. Symptoms are thought to develop from the interaction among the following 3 components:

• The static component results from enlargement of the inner portion, or transition zone, of the prostate. This zone is adjacent to the urethra and develops into an adenoma that compresses the peripheral zone. The transition zone is the tissue that is removed when a prostatectomy is performed, via transurethral resection, open prostatectomy, or any of the other types of procedures.
• The second, dynamic component involves the smooth muscle in the prostate, the prostatic capsule, the bladder outlet, and the proximal portion of the urethra.
• The third component is the bladder muscle (detrusor), which responds to changes related to prostate growth and tension in the smooth muscles within the prostate and proximal urethra. The bladder exhibits a decrease in contractility that leads to atony and urinary retention, an increase in uninhibited contractions that produces frequency and urgency, or a combination of both.

Enlargement of the prostatic adenoma produces changes in the detrusor that are responsible for many of the symptoms that men experience. The smooth muscles that encircle the urethra and course through the prostate are responsible for maintaining muscle tone in the urethra. The dynamic changes in these smooth muscles result in symptoms of frequency, urgency that may be accompanied by urge incontinence, nocturia, and postvoid dribbling. These LUTS tend to occur in men younger than 65 years. Often, these men have prostates that are not very enlarged and have relatively good flow rates and empty their bladders fairly well.

The static or obstructive symptoms, which usually occur in older men, include a weak stream, hesitancy, inability to complete urination suddenly without postvoid dribbling, sensation of incomplete bladder emptying, straining to urinate, and urinary retention (in some men). These symptoms are associated with an enlarged prostate.

• Category 1: Although a weak stream often is associated with BOO, other disorders (eg, urethral stricture) can produce the same symptom. Researchers define hesitancy as an increase in time from the attempt to initiate micturition and the actual start of the urinary flow. In men without a prostate condition, the start of urinary flow usually takes only a few seconds, but, in men with obstruction, it may take several minutes.
• Category 2: This category defines irritative symptoms, including frequency and urgency, which may be coupled with some incontinence and nocturia. Urination frequency depends on many factors (eg, fluid intake, diet, medications, physical activity). Voiding at intervals of less than 2 hours with voided volumes less than 250 mL arbitrarily can be defined as frequency. Urgency describes the sudden, strong desire to urinate and may be associated with incontinence.

This symptom constellation causes most patients to seek medical attention. Most men have some, or many, of these symptoms in various degrees by the age of 70 years. The severity of symptoms and their correlation with urodynamic findings provide the basis for therapeutic intervention.

Frequency

Histologic evidence in unselected autopsy specimens demonstrates that BPH occurs in more than 40% of men aged 50-60 years and in 90% of men aged 80-90 years. The majority of men older than 50 years have some symptoms attributable to BPH. Nearly 2 million office visits per year are from men seeking the evaluation and treatment of BPH. Surgeons perform more than 300,000 procedures per year on the prostate, and an estimated 900,000 men take some type of medication or herbal supplement for a prostate condition.

Approximately 25% of men aged 55 years note a decrease in the force of urine flow, and 50% of men describe this symptom by age 75 years. According to the International Prostate Symptom Score (IPSS) index, the odds of a man aged 40-50 years developing moderate-to-severe symptoms (IPSS >8) increases with age, from 1.9 for men aged 50-59 years to 3.4 for men aged 70-79 years. The chances of men developing moderate-to-severe symptoms with a prostate larger than 50 g is 3.5 times greater than for men with smaller prostates; however, epidemiologic and clinical studies demonstrate that the relationship between prostate size and symptoms is not necessarily linear.

The proportion of men with clinical prostatism at any age is approximately the same as those with pathologic evidence of BPH, even though the correlation is poor between symptoms and prostate size. The dynamic or smooth muscle component associated with the symptoms of BPH explains this discordance; thus, some men with relatively small prostates may have severe symptoms, and some men with very large prostates may have few symptoms.

Patients' symptoms affect their quality of life. Interference with at least 1 daily activity occurs in 50% of patients, and 25% of patients report interference with activity most, or all, of the time.

Epidemiologic studies fail to demonstrate racial differences in prevalence of BPH histopathology, prostate size, or clinical diagnosis.

An inheritable form of BPH may be present in 50% of men younger than 60 years who are treated for this disease. Only 9% of men older than 60 years who are treated for BPH are predicted to have a familial risk. A large prostate size and a mean volume of 82.7 mL in men with hereditary BPH, compared to 55.5 mL in men with sporadic BPH, characterize BPH.

Etiology

BPH is characterized by an increase in the number of epithelial and stromal cells in the periurethral area, or transition zone, of the prostate. Embryonic reawakening describes the presence of new epithelial gland formation. Increases in cell numbers may occur from epithelial and stromal proliferation or apoptosis impairment.

Etiology of the hyperplastic process relates to androgens, nonandrogen testicular factors, estrogen, stromal-epithelial interactions, growth factors, neurotransmitters, and other factors awaiting definition.

The two causative factors necessary for the development of BPH are aging and the presence of functional testes. The prostate is able to grow throughout adult life, and the process may be clinically evident in men as young as age 30-40 years.

The prostate consists of a network of glandular elements embedded in a fibrostromal network with a rich vascular supply. Androgens, estrogens, other growth factors, and various cytokines mediate the close interaction between these glandular and stromal cells. The growth process within the stroma perpetuates itself and exerts control on the gland growth rate and apoptotic cycle. The urine and semen also contain growth factors that may permeate the urethra and influence epithelial cell growth. Interactions between growth factors and steroid hormones may alter the balance of cell proliferation versus apoptosis.

BPH involves growth stimulatory factors with dihydrotestosterone (DHT) and other hormones modulating their effects, which are as follows:

• Epidermal growth factor
• Epidermal growth factor receptor
• Insulin growth factors 1, 3, 4
• Insulinlike growth factor (IGF) receptors and binding proteins
• Beta fibroblast growth factor
• Keratinocyte growth factor (KGF): It is produced in stromal cells, but its receptors are located on the glandular epithelial cells. Its hormonally regulated production plays a key role in stromal-epithelial interaction

The transforming growth factor beta inhibits epithelial cell proliferation, regulates extracellular matrix synthesis and degradation, and can induce apoptosis.

The role of the testis in BPH involves the production of androgen, estrogen, and nonandrogenic substances. These 2 hormones play a pivotal role in prostatic growth because the prostate is androgen-dependent and estrogen is mitogenic. The nuclear membrane-bound enzyme, 5aR, mediates the biochemical action of testosterone and is responsible for the conversion of testosterone to DHT (ie, the active agent within the cell). Patients with BPH maintain intraprostatic levels of DHT, but these levels are not elevated. DHT levels are the same in hyperplastic and healthy glands.

In adult prostates, androgen receptors are present on glandular and stromal cells, but 5aR is present only in stromal cells. Two 5aR enzymes are encoded by separate genes. Type 1 is the predominate enzyme in extraprostatic tissues, and type 2 is found largely in the prostate.

BPH also seems to have an inheritable genetic component. The hazard-function ratio between men treated surgically for BPH compared to first-degree male relatives of the controls was 4.2, indicating a very strong relationship. A segregation analysis shows that results are consistent with an autosomal dominant inheritance pattern.

Pathophysiology

Benign prostatic hypertrophy

The traditional BPH symptom complex is initiated by enlargement of the prostate, which leads to BOO and its associated symptomatology. However, prostate size, per se, does not determine the severity or the symptom complex associated with this condition. Some men with prostates larger than 75 mL have minimal difficulty voiding, have good flow rates, and empty their bladders. Some men have minimal prostatic enlargement with severe symptoms and need some type of intervention.

Lepor et al report on the results of over 400 men enrolled in the terazosin database. Their research could demonstrate no correlation between prostate size and either peak urinary flow rates or symptom scores. They conclude that treating patients just because of an enlarged prostate may not always relieve obstruction or improve symptoms.

The following mechanisms explain why BPH may produce BOO:

• Enlarged middle lobe of the prostate, which acts as a ball valve
• Static obstruction, resulting from an enlarged prostate encircling the urethra
• Dynamic obstruction related to the contractile properties of the prostatic smooth muscle
• Restrictive prostatic capsule
• Smooth detrusor muscle tension

Controlled, randomized studies that focus on reducing prostate size and relaxing prostate smooth muscle consistently demonstrate improvement in flow rates and symptoms.

Prostatism

The prostatism theory postulates that increases in urethral resistance, which usually are associated with prostatic hyperplasia in the periurethral glands of the transition zone, result in compensatory changes in detrusor function. The resulting elevated detrusor pressures that are required to maintain urinary flow when outflow resistance is increasing occur at the expense of normal bladder function.

Changes in detrusor function (caused by obstruction), combined with incremental increases in smooth muscle tension and a resistant prostatic capsule and compounded by age-related changes in the detrusor and the nervous system, produce the characteristic symptoms of frequency, urgency, nocturia, and weak urine flow associated with prostatism.

Presentation

Symptoms that characterize BPH and distinguish the need for some type of intervention of the prostate are as follows:

• Prostatism can be separated into an obstructive or irritative (dynamic) component: The typical obstructive symptom is a weak flow, which is not pathognomonic of obstruction because other entities (eg, urethral stricture) can produce the same symptom.
• Hesitancy in beginning urination: This is described as a prolonged time between patient attempt to initiate voiding and time that voiding actually begins. Normally, this interval takes only a few seconds, but it can take several minutes in men with severe obstruction whose bladder cannot generate enough pressure to overcome urethral resistance.
• Patient inability to abruptly terminate urination results in postvoid dribbling, which is caused by detrusor fatigue or urine trapped in the bulbar urethra. This particular symptom often develops in healthy men.
• Sensation of incomplete bladder emptying is frequent but does not necessarily correlate with ultrasound measurements of residual urine.
• Overflow incontinence occurs when the detrusor is unable to contract and urine begins spilling through the urethra. This usually is associated with large residual urine or urinary retention.
• Urinary retention
  • This occurs when a patient suddenly is unable to void. Retention is also defined as a bladder that consistently retains more than 150 mL after voiding, as determined with Foley catheterization or bladder scanning.
  • In some patients, total urinary retention represents the terminal event of steadily progressive urinary obstruction and detrusor decompensation. Some type of invasive procedure is necessary in most of these men, although the recovery of detrusor function is variable and depends on how long the retention has been present. Urodynamics may provide information that predicts bladder recoverability.
  • Alcohol, antidepressants, anticholinergics, tranquilizers, and antihistamines with alpha-adrenergic activity also may cause retention. This can be reversed in some men with cessation of these agents.
• Irritative symptoms (thought to develop from detrusor instability and not directly related to obstruction)
  • Frequency
  • Nocturia
  • Urgency
  • Urge incontinence
• Frequency
  • To determine whether patient frequency is physiologic or attributable to detrusor instability, evaluate voiding times and compare them with the volume of passed urine.
  • Patients taking diuretics, those with large fluid intakes, and patients with a large caffeine intake often void frequently but pass substantial amounts of urine with each voiding. Normal voiding volumes diminish with age, but most individuals can expect to pass 250-300 mL of urine with each void.
  • Abnormal frequency includes patients with a strong urge to urinate at intervals of less than 2 hours, with volumes that average less than 200 mL.
• Urgency
  • This refers to the sudden and strong need to urinate, and incontinence may accompany this symptom.
  • This is a nonspecific symptom, which may be associated with prostatism but also occurs in patients with bladder stones, neuropathic bladder disease, bladder cancer, and some types of inflammatory bladder disease.
• Nocturia occurs in many patients but must be correlated with fluid intake, sleep patterns, and medications. Nocturia occurring more than once may be abnormal in some but readily explainable in others. Nocturia is probably the single most difficult symptom to treat in men with LUTS.

Indications

Indications for treatment depend on patient symptoms and their severity, the degree to which the symptoms bother the patient, and whether changes in bladder and renal function can be documented objectively. Some men have relatively few symptoms but are extremely bothered by them and desire therapy. Others may have significant symptoms but are quite content to live with them. Still others may have minimal symptoms but serious impairment of bladder and/or renal function.

Many men with mild-to-moderate symptoms or objective findings generally may respond to alpha-blockers, 5aR inhibitors, and herbal products such as saw palmetto and Pygeum africanum. Combinations of these agents are also used. Other interventional strategies should be used if the symptoms are not ameliorated to the patient's satisfaction, which can be judged based on an improvement in their symptom scores, or upon objective findings such as a decrease in urine flow rates, an increase in the postvoid residual, or deterioration of renal function. Some men develop side effects caused by these various agents and want the problem resolved permanently and expeditiously.

Review the options and create a management strategy if the patient's symptoms correlate with the objective data gathered from an evaluation of the urinary tract and the patient desires or needs therapy.

Absolute indications for intervention

• Urinary retention
• Upper urinary tract obstruction secondary to benign prostatic hyperplasia (BPH)
• Diminished renal function caused by BPH
• Gross hematuria due to BPH (although this can be managed with medical therapy with 5aR inhibitors)
• Recurrent urinary tract infections
• Bladder calculi
• Progressive deterioration of bladder function - Demonstrated by an increase in the amount of residual urine or decreased bladder muscle tone and pressure on cystometrogram (CMG) or pressure-flow studies
• Overflow urinary incontinence

Some men have silent prostatism in which serious deterioration of the bladder and/or renal function occurs with relatively few urinary symptoms.

Relative indications refer to the patient's symptoms and his desire to improve the clinical situation. Use the IPSS index to evaluate and follow the cases of these patients because the patient himself usually has difficulty recognizing changes in voiding, which often are subtle and somewhat variable daily.

After making the decision to intervene, determine next whether to alter the pharmacologic therapy or initiate some type of invasive procedure.

Interstitial laser coagulation therapy

• Interstitial laser coagulation (ILC) therapy is among the choices of invasive therapy.
• Most patients are not familiar with this particular method for treating BPH.
• Almost any patient who is a candidate for an invasive procedure is eligible for ILC.
• An advantage of this technique is that it can be offered to anyone regardless of age, symptoms, configuration of the prostate, or severity of symptoms.
• Usually, minimal blood loss occurs.
• Patients require only a short hospital stay, or the procedure can be performed on an outpatient basis.
• Patients do not experience any adverse effect on potency.
• The procedure can be performed with a regional or local anesthesia.
• Urologists can perform this procedure in their offices.
• Ensure that the patient is not taking anticoagulants during the preoperative period because of potential bleeding from the multiple prostate perforations.
• Some patients need to be able to manage a Foley catheter while at home, usually for 5-7 days.

Relevant Anatomy

Anatomy relevant to interstitial laser coagulation (ILC) therapy is assessed with a cystoscopic examination. The prostate consists of glandular elements embedded in a fibrostromal network with a rich vascular supply. Androgens, growth factors, and cytokines produced by the stromal cells mediate this interdependent relationship.

The development of benign prostatic hyperplasia (BPH) begins in a specific portion of the prostate, the transition zone, which encircles the urethra. This hyperplastic growth is initiated in men aged 30-35 years. Symptoms are thought to develop from the interaction among the following 3 components:

• The static component results from enlargement of the inner portion, or transition zone, of the prostate. This zone is adjacent to the urethra and develops into a hyperplastic adenoma.
• The second, dynamic component, involves the smooth muscles in the prostate, the prostatic capsule, the base of the bladder, the bladder outlet, and proximal portion of the urethra.
• The third component is the bladder muscle (detrusor), which responds to these changes in the prostate with a decrease in contractility, an increase in uninhibited contractions, or a combination of both. The detrusor becomes hyperplastic and increased fibrotic tissue diminishes the elasticity of the bladder.

Contraindications

Few absolute contraindications exist for this procedure. Relative contraindications are as follows:

• Coagulopathies that are not reversible
• Active infections
• Prostates larger than 80 g
• Patient inability to manage a catheter after surgery

Workup

Laboratory Studies

• Conduct a urinalysis, which includes dipstick testing and a microscopic examination, and a urine culture to evaluate the patient for possible infection and hematuria.
• Determine lateral lobe length to establish how many probe insertions are necessary to treat each lobe. A 3-cm area of coagulation necrosis develops in each treated area.
• Obtain cytology to evaluate men with severe irritable symptoms (particularly with a history of smoking or microscopic hematuria) for possible bladder cancer (carcinoma-in-situ).
• Obtain a urine culture and sensitivity for men with a WBC count more than 5 per high-power field (HPF) on spun urine sediment.
• Renal function
  • Evaluate patient renal function with a serum creatinine.
  • Risk of complications increases for patients with renal failure.
  • If the creatinine level is elevated, conduct imaging studies or isotope renography to evaluate for upper urinary tract obstruction.
• Measure the serum prostate-specific antigen (PSA) as a baseline and use it to determine whether a prostate biopsy to evaluate the patient for possible prostate cancer is necessary. These 2 disorders coexist in many men, and therapy is significantly altered if cancer is present.
• One of the disadvantages of ILC and the other procedures is that no tissue is obtained.

Imaging Studies

• Residual urine determination: Perform an ultrasound of the bladder following voiding to evaluate the amount of residual urine. This helps to assess the muscle tone and function of the patient's bladder, but it also reflects the status of the bladder outlet obstruction (BOO).
• Upper urinary tract imaging
  • Obtaining imaging studies of the upper urinary tract depends on the patient's situation. These studies should be performed in patients with hematuria, flank pain, a history of stone disease, or elevated serum creatinine levels. The physician needs to decide the necessity of these studies.
  • Conduct an ultrasound, a CT urogram, or an intravenous pyelogram, depending on the clinical situation and renal function.
• Determine the relevant anatomy, which is the configuration of the prostate related to interstitial laser coagulation (ILC) therapy, with cystoscopic examination and ultrasonography.
• Conduct a transrectal or suprapubic ultrasound of the prostate to help measure the prostate length and determine the presence of a middle lobe. The presence of a middle lobe is not a contraindication to this procedure; in fact, middle lobe hyperplasia is well suited for this technique.

Other Tests

• Uroflowmetry
  • A uroflow test involves the patient urinating into a device that measures the urine volume passed, peak flow rate, and average flow rate. Then, it provides a graph detailing the flow characteristics.
  • In most men, decreased uroflow results (<10 mL/s) indicates obstruction. However, without concomitant measurement of detrusor pressure, detrusor failure and obstruction are indistinguishable. A pressure-flow study is indicated to differentiate between these two entities. Greater than 15 mL/s is a normal uroflow, and 10-15 mL/s is equivocal.
  • Compare this test information with age-matched reference ranges. The style and character of the flow curve is more important than absolute numbers. One can exhibit a normal Qmax (maximum uroflow) and still be obstructed if the peak is transient and isolated. A staccato pattern, long voiding times, or a prolonged flat curve can indicate obstruction.
  • Use that information to determine whether the patient's condition is deteriorating or to evaluate the patient's response to therapy.
  • If the voided volume is less than 150 mL, the test likely is inaccurate and unreliable.
• Questionnaire
  • Instruct the patient to complete a symptom assessment questionnaire. This helps to evaluate symptom severity, to assess response to therapy, and to detect symptom progression in men who are not on therapy or are taking some form of oral treatment. Most urologists employ the American Urological Association (AUA) symptom score index.
  • Each of the 7 questions can yield a score of 0-5. A quality-of-life is also scored on a scale of 0-5. This may provide insight into the patient's opinion of his own symptoms.
  • Patients with total scores of 0-7 have minimal symptoms and rarely require or need any type of therapy.
  • Scores of 8-19 indicate moderate symptoms and patient discomfort; however, many patients do not need therapy, and those that do generally benefit from medication and phytotherapy.
  • Symptom scores greater than 20 imply significant symptoms, but they do not always correlate with significant patient discomfort. Men with this score often benefit by some type of therapy.

Diagnostic Procedures

• Pressure-flow studies
  • Compared to uroflowmetry, pressure-flow studies provide more specific information about detrusor function and the etiology of the voiding dysfunction.
  • Perform these studies to help differentiate between patients with a low–peak flow rate caused by obstruction and those with a decompensated or neurogenic bladder.
  • These studies also may identify high-pressure obstruction in symptomatic men with normal flow rates.
  • This data may be particularly useful in men who are planning to have surgery or those who have had a previous surgery because it distinguishes between bladder dysfunction and outflow obstruction.
  • Two independent variables: Although pressure-flow studies provide valuable information for clinical decisions, they do not correlate necessarily with symptom scores.
• Cystourethroscopy
  • This rarely is necessary to diagnose or evaluate patients with benign prostatic hyperplasia (BPH). Many urologists perform this test routinely in the evaluation of men with lower urinary tract symptoms (LUTS).
  • Conduct cystourethroscopy in patients with gross or microscopic hematuria, urethral stricture disease, history of urethral trauma, history of bladder cancer, or prior lower urinary tract surgery. In addition, this study can be performed if the treating urologist feels it will aid in treatment planning.
  • Also, conduct this procedure to confirm suspicion of a bladder stone or to help determine the most appropriate invasive procedure.

Histologic Findings

The prostatic tissue treated with ILC undergoes coagulative necrosis. Each treated area has approximately 2-3 mL of tissue destruction. Sloughing of necrotic tissue in the urine may occur if coagulation of the urethra is evident, but this is minimal and most of the tissue is absorbed over 6-8 weeks. No tissue is obtained from this procedure for the pathologist to examine.

If the PSA is elevated or if a suspicion of prostate cancer exists, biopsies should be obtained prior to any therapy.

Treatment

Medical Therapy

Medical treatment therapy of benign prostatic hyperplasia (BPH) consists of 3 classes of agents: alpha-adrenergic blockers, 5aR inhibitors, and phytotherapeutics.

Alpha-adrenergic blockers

These represent a class of medicines that affect the rich supply of alpha-adrenergic receptors in the smooth muscles at the base of the bladder, the bladder outlet, and the smooth muscles within the prostate and proximal urethra. Blocking these receptors reduces tension in these smooth muscles, relieving the irritative symptoms manifested by urgency and frequency and improving urinary flow.

Several subtypes of the alpha-adrenergic receptors have been identified. The primary alpha-receptors in the prostatic urethra are alpha-1a and alpha-1d. The prostatic stromal tissue is largely alpha-1a. Alpha-adrenergic blockers can be divided into 3 groups, depending upon the affected receptor and their duration of action—nonselective, selective, and selective long acting.

The alpha-receptors in prostatic stromal tissue are largely the alpha-1a subtype. Inhibition of these receptors in the prostate and prostatic urethra reduces the symptoms associated with bladder outlet obstruction (BOO). Inhibition of the alpha-1d receptors diminishes the irritative symptoms, which frequently accompany this condition.

The 4 most common agents include terazosin, doxazosin, tamsulosin, and alfuzosin. These agents have similar therapeutic effects. They improve voiding dynamics and provide symptom relief. In contrast to the nonspecific inhibitors, these agents are long acting (once-per-day dosing) and have fewer adverse effects. Long-term outcome studies of these drugs indicate that their effectiveness persists indefinitely. Because they do not affect prostate growth, patients who are receiving only alpha-blockers often develop increasing difficulty with urination as their prostate enlarges.

Nonselective blockers were the first agents found to be effective but are rarely administered today because of adverse side effects. Selective alpha-adrenergic blockers include prazosin (Flomax), alfuzosin (UroXatral), and terazosin (Hytrin). These agents have fewer side effects compared with the nonselective alpha blockers. Recently, a new alpha-1a receptor selective blocker, silodosin (Rapaflo), was approved.

The most common adverse effects, which occur in less than 20% of patients, include dizziness (19%), postural hypotension (6%), lightheadedness, asthenia (6%), and nasal stuffiness. No sexual dysfunction develops, but all of these agents except alfuzosin may cause retrograde ejaculation. This is an advantage for many men.

Tamsulosin and alfuzosin are the most selective of these agents for the prostate/bladder receptors. Dizziness and lightheadedness are problematic for some patients; those who are taking antihypertensive medications need to be cautious when they first start these medications. The use of these agents in conjunction with any of the 5-phosphodiesterase inhibitors used in the treatment of erectile dysfunction is not contraindicated.

5-Alpha reductase inhibitors

These medications, finasteride and dutasteride, inhibit the 5aR enzyme responsible for the conversion of testosterone into DHT.

Two genes produce this enzyme. Type 2 is located predominately in the prostate and is blocked by both agents, but dutasteride also blocks type 1. This dual action is more effective in lowering DHT levels. DHT is the active agent within the cell, and, by decreasing its level, cellular function is altered and the glandular component of the prostate atrophies.

Prostate size is reduced and PSA levels are lowered because of these alterations. The PSA level is usually decreased by 50% after 6 months of therapy. A multiplier of 2 converts the PSA to a level that can be comparable with levels obtained prior to the institution of therapy. This PSA level reduction persists so that the multiplier is 2.5 at 7 years.

The 5aR inhibitors significantly affect the prostate but do not always translate into symptomatic improvement. Patients who are most likely to benefit are those with symptoms that are primarily due to prostate glandular hyperplasia and in men whose prostates are 40 mL or larger. Unfortunately, determining how much of the obstruction relates to glandular or stromal hyperplasia is not easy. Six months of treatment or longer is necessary to achieve the maximum benefit from this type of medication.

Because they affect prostate growth patterns, 5aR inhibitors should theoretically be effective over a long period. A study compared the effects of an alpha-blocker, a 5aR inhibitor, a combination of the two, and placebo. The combination therapy was shown to be more efficacious than either single agent, and all showed better results when compared with the placebo control group.

The combination of these agents is helpful in reducing the incidence of urinary retention. Patients with BPH who are at very high medical risk of surgery should receive these agents to help prevent further prostatic enlargement.

They also are useful in reducing bleeding caused by invasive prostate surgery such as TURP. When used for this purpose, at least 2 weeks of therapy is recommended, and 2 months may be even better, when possible.

The agents that shrink the prostate the fastest are the luteinizing hormone–releasing factor (LHRH) agonists or antagonists, which work by suppressing testosterone production. These agents and the antiandrogens, which block the androgen receptors on the cell, are used to treat prostate cancer. They are not approved for use in BPH; however, short-term use is effective, particularly for men with urinary retention.

The most frequently used phytotherapeutics include saw palmetto, which is the fruit of Sabal serrulata (Serenoa repens), the root of Hypoxis rooperi, the bark of Pygeum africanum, pollen extract, the seeds of Cucurbita pepo, the leaves of the trembling poplar, and the roots of Echinacea purpurea.

Various mechanisms explain their actions, as follows:

• Antiandrogenic effect
• Antiestrogenic effect
• Decrease in sex hormone–binding globulin
• Inhibition of fibroblast and epidermal growth factors
• Interference with prostaglandin metabolism

Phytotherapeutic agents usually are offered in combinations. Preliminary studies show that some patients claim symptom improvement, which has led to further investigations indicating that potential benefit of these agents exists in men with mild-to-moderate symptoms.

No specific dosage is indicated for these agents. The recommendations of the manufacturer can be followed. Many of these agents are available in combinations. No specific adverse effects have been reported for these agents, but concerns have been raised about their use prior to surgery and the possibility of a coagulopathy.

Surgical Therapy

Various interventional therapies are available to treat patients in whom medical therapy has failed or is not tolerated because of adverse effects.^2,3 In some instances, the changes in a patient's urinary tract may have progressed to the point that medical therapy is inappropriate. Patients with hydronephrosis, renal insufficiency caused by obstruction, urinary tract bleeding, recurrent infections, or bladder stones need to have an immediate remedy and often should not wait until medications become effective.

Invasive surgeries include retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy.⁴ These procedures are usually performed in men with prostates larger than 80 mL in volume, when concomitant large bladder stones are present, or an associated problem needs to be surgically corrected.⁵

Minimally invasive surgery can be performed in most patients. These procedures can be performed with general, spinal, epidural, or conscious sedation or local anesthesia. These surgeries are usually performed on an outpatient bases either in the hospital, a surgery center, or in the office.

Transurethral resection of the prostate

For years, the standard surgical treatments were TURP or open prostatectomy (eg, classic suprapubic prostatectomy, retropubic prostatectomy).

These procedures have been proven to offer patients the most rapid symptom relief for a long duration. They offer minimal mortality rates, low morbidity, and the opportunity for permanent symptom relief.

In the past 10 years, less invasive procedures have been introduced. These include transurethral needle ablation (TUNA), which is a radiofrequency tissue-ablation therapy that can be performed in the office with local anesthesia. A current is passed through the antennae after insertion through a cystoscope. The antennae are extended from the probe and inserted into the prostatic tissue The microwave radiofrequency transmission produces heat between the 2 antenna needles. The heat is produced for a defined time, usually 2-3 minutes, and the antennae are withdrawn and inserted into a different part of the prostate. This process is repeated until the lateral lobe tissue is thoroughly treated. Middle-lobe tissue has been difficult to treat, but newer probes can treat these lobes. In properly selected patients, the results seem to be comparable with those of similar technologies.

Water intensity hyperthermia (WIT) is an office-based procedure in which a special 2-balloon catheter is placed into the bladder. One balloon is inflated in the bladder to hold it in position. The second is inflated within the prostatic urethra to a dimension of approximately 50 F. Hot water (45°C) is circulated through this balloon for 45 minutes. Patients usually need to wear a catheter for 7-10 days. This procedure has not been shown to have long lasting benefit, nor does it relieve the symptoms in many patients.

Transurethral microwave thermotherapy (TUMP) is a minimally invasive procedure that can be performed in the office. These procedures involve placing a specially designed catheter into the urethra and a temperature probe into the rectum. The prostate is heated for about 30-60 minutes, depending on the device, and the prostatic temperature should exceed 45°C.

Trock et al⁶ reported on the results of 541 men from 6 institutions who were treated with the Targis cooled thermotherapy system. Compared with baseline measurements, the AUA symptom score improved by 55%, peak urine flow increased by 51%, and quality-of-life scores by 53%. The authors noted that it may take 6 months before the maximum benefits have been obtained.

Interstitial laser therapy

Interstitial laser coagulation (ILC) candidates include men with obstructive uropathy from BPH and the following:

• Patient no longer wants to take medication
• Medications are not effective or cause adverse effects
• Patients taking anticoagulants
• Poor surgical candidates
• Men who wish to avoid retrograde ejaculation
• Men concerned with impotency caused by one of the standard procedures
• Men in urinary retention
• Men who are obstructed with prostate cancer

Newer procedures include the following:

• Bladder neck and prostate transurethral incision
• Transurethral electrovaporization
• Transurethral needle ablation using radiofrequency energy
• Intraurethral stents
• Hyperthermia with microwave energy
• Thermotherapy
• High-intensity focused ultrasound
• Prostatic injections with alcohol to produce tissue necrosis
• Intraprostatic injections with BOTOX® to paralyze the smooth muscles in the urethra and prostate
• Various laser procedures

Laser techniques include the following:

• Side-firing YAG lasers (may be visualized through a cystoscope or ultrasound)
• Visual side-firing contact vaporization (PPV)
• Laser resection using a holmium-YAG laser^7,8
• Laser balloon therapy
• Green light laser therapy⁹
• Interstitial laser therapy

Advantages of laser therapy include the following:

• Minimal bleeding
• No TURP syndrome; less irrigation fluid is used during the procedure
• Patients on anticoagulants can be treated.
• Short learning curve
• Less chance for retrograde ejaculation
• Procedures can occur on an outpatient basis or in the office.

Disadvantages of laser therapy include the following:

• New techniques without long-term follow-up studies
• No tissue for the pathologist
• Catheter stays in place for a longer period of time compared to a TURP.
• Delay in achieving desired result
• Irritative symptoms last longer.
• Equipment and fibers are expensive.

Preoperative Details

• Evaluate the prostate anatomy prior to the procedure to assist the surgeon with the proper procedure plan.
• Conduct urodynamic testing with uroflowmetry and pressure-flow studies if clinically indicated.
• Using rectal examinations and PSA, carefully evaluate patients for the presence of prostate cancer.
• Because no tissue is obtained with ILC, consider performing a prostate ultrasound (to determine the size of the gland) and a biopsy prior to ILC surgery.
• Some urologists have suggested limiting this procedure to patients with prostates less than 40 g. However, this author and others have treated patients with 100-g prostates, and they have improved, although patients with smaller prostates are better candidates.
• An enlarged median lobe is not a contraindication for ILC. Some experts have suggested that the enlarged median lobe be treated with either transurethral laser incision or transurethral vaporization while the ILC is performed on the lateral lobes. This sometimes involves a change in instruments and extends the time of the procedure, but it has worked well.
• Start patients with infected urine on antibiotics several days prior to the procedure.
• Perform bowel cleansing in some patients to avoid straining in the postoperative period.
• Inform patients that they will have a catheter in place at the conclusion of the procedure. The time involved for the edema induced by the procedure and satisfactory urination to occur takes days to weeks, although 5-7 days is common in uncomplicated cases.
• Consider starting the patient on Proscar at least several weeks before the procedure to help minimize operative and postoperative bleeding. This is most helpful in patients who are on anticoagulants and in people with larger prostates.

Intraoperative Details

• Consider using a regional anesthetic, spinal or epidural, or local anesthetic (periprostatic block) for this procedure.
• Consider infiltrating the periprostatic area with a local anesthetic, instilling the urethra and bladder with a soluble anesthetic, inserting a belladonna and opium (B&O) rectal suppository, and providing the patient with an intravenous sedation.
• Place a 23F cystoscope sheath into the urethra under direct vision and inspect the prostatic urethra and bladder. If the patient has a bladder neck contracture from fibrous tissue or a very large middle lobe, consideration can be given to incising the bladder neck with a bare-tip laser fiber. This fiber is available with the indigo laser system. This would lessen the chance of further obstruction, but it also increases the risk of retrograde ejaculation. Alternately, transurethral vaporization can be used. The lateral and middle lobes can be treated with the ILC probe.
• Insert the laser probe into the open port of the endoscopic instrument until the tip is visible. The end of the probe has a fine point to facilitate its introduction into the tissue, and a circular black band on the probe is located 1 cm from the end. Accurate placement of the fiber is critical in achieving a good outcome. Using a stabilizing element helps to direct the probe into the desired location.
• Determine the configuration of the prostate. Note its length, the presence of a middle lobe, and the location of the verumontanum.
• The middle lobe can be treated first.
• Probe placement is critical. Advance the probe through the cystoscope and insert it directly into the base of the middle lobe tissue. The probe usually is introduced at least as far as the black band, but the depth of insertion should vary according to the size of the prostate. The probe may be advanced further for very large middle lobes or to a lesser degree in small glands. Usually a single probe placement is adequate, but an additional probe insertion and treatment may be necessary for large middle lobes. The probe will produce an area of tissue destruction of about 3 mL as long as the desired temperature is maintained for 80% of the time.
• Activate the laser unit with the foot pedal so the temperature will begin to increase.
• If the probe is placed properly, the temperature will rise to 80-85°C within the first half-minute and remain at that temperature for the duration of the therapy. If the temperature does not rise quickly, the probe is likely placed improperly. The tip of the probe may be in the bladder or just superficial in the urethra. If this occurs, retract or reinsert the probe until the temperature begins to rise and is sustained at the appropriate level. If retracting beyond the black mark is necessary, stop the laser treatment to avoid proximal laser injury.
• Hold the probe in position for 1.5 or 3 minutes depending on the device being used. Afterward, the laser unit automatically stops supplying energy. Probe position needs to be monitored continuously because altering its position is easy while attempting to hold the probe still. A video system is recommended for this purpose.
• Withdraw the laser probe and place it into a new site.
• Depending on the length of the gland, usually treat 2 areas of each lateral lobe by inserting the probe into the tissue to the depth of the black band, or deeper for large glands, and activating the laser unit. The areas of tissue necrosis may overlap. If the probe is introduced into a site that has been treated previously, the temperature rises very rapidly and selecting a different site may be necessary. No harm exists in creating overlapping areas of tissue destruction. If the probe is inserted too deeply and enters the bladder, the temperature will drop, indicating poor probe placement.
• Many patients have glands 40-60 mL in size; therefore, 5 insertions are adequate if a middle lobe is present. More insertions are not necessarily better because the position of each treated area seems to be the most important feature.
• Glands in the 100-mL range may require 8-10 insertions; 2 in the middle lobe and 4 in each lateral lobe.
• Drain and irrigate the bladder often to maintain visibility because each puncture into the prostate produces some bleeding. Do not use heated water for irrigation, which would affect the temperature readings and make determining when the probe tip is out of position or has entered the bladder more difficult.
• Usually, one probe is adequate for each procedure, but probes are known to burn out or break; therefore, ensure that a second probe is available, particularly if treating a large prostate.
• At the conclusion of the procedure, insert a Foley catheter. Use a 20-22F, 3-way catheter if the bleeding is moderate so that continuous 3-way irrigation can be performed. Otherwise, a standard Foley can be used. A B&O suppository can be inserted for postoperative analgesia if not inserted earlier.
• Place a suprapubic tube in patients with atonic bladders who may require catheter drainage for several weeks or longer or if the patient cannot tolerate urethral catheters. This is advantageous in determining when the patient is urinating well enough to remove the catheter, without having to go through a series of catheter removals and replacements.

Postoperative Details

• In the recovery room, follow surgeon discretion and the level of bleeding to decide whether to connect the catheter to 3-way irrigation or straight drainage. The authors' preference is to use 3-way irrigation immediately postoperatively, then convert to straight drainage and plug the irrigation channel when appropriate. The duration of catheter drainage is at the discretion of the physician.
• After the anesthetic wears off and the patient's condition stabilizes, he may be discharged with the catheter or keep the patient overnight in the hospital. Many elderly, fragile men remain in the hospital unless someone at home is capable of caring for them.
• Instruct the patient on how to care for the catheter, whether it is a urethral or suprapubic tube.
• Maintain antibiotic therapy while the catheter is in place and for 3-5 days after the catheter has been removed. Sometimes a urinary antibiotic, such as nitrofurantoin, may be sufficient. Some patients will require an anticholinergic, such as oxybutynin, to help limit bladder spasms while the catheter is in place.
• Following removal of the catheter, employ antibiotics if a urinary infection is evident.
• Allow the patient to become ambulant after returning home and with minimal restrictions.
• Inform the patient that no dietary restrictions are necessary and that resuming any preoperative medications is safe. Limiting caffeine intake while the catheter is in place may help reduce any bladder spasms.
• If the patient was taking coumadin, ensure that the urine is clear before the patient resumes that medication or, if needed, treat the patient with injections of Lovenox.

Follow-up

• Patients may return to the office 5-7 days following the procedure.
• If the patient is doing well, remove the catheter after filling the bladder for a voiding trial.
• If the patient can void, the catheter can be left out. If not, replace the catheter.
• Patients with suprapubic catheters can have this tube plugged or clamped. If they are urinating without difficulty and emptying the bladder reasonably well, remove the catheter either immediately or several days later.
• The pattern of normal urination is not anticipated to occur for approximately 6 weeks, although voiding continues to improve at 6 months. After this period, patient voiding problems greatly diminish and the patients tend to be free of problems for a long period of time.
• Follow uroflow determinations, symptoms scores and residual urine measurements to check patient recovery progress.
• Check the urine for signs of infection.
• After 3 months, a PSA can be obtained to establish a new baseline.
• Additional follow-up studies are performed at the discretion of the urologist.

For excellent patient education resources, visit eMedicine's Prostate Health Center and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Enlarged Prostate and Bladder Control Problems.

Complications

Bleeding

The initial complication associated with interstitial laser coagulation (ILC) is bleeding that may last for several days and may occur intermittently for several weeks. Muschter and Hofstetter report significant hemorrhage in 5 of 239 (2.1%) patients, with 1 requiring a transfusion.¹⁰ The laser produces excellent tissue coagulation and hemostasis; however, the multiple punctures into the prostate produce bleeding that can last several days. This is particularly true in patients receiving anticoagulants. The bleeding is self-limiting, but leaving the catheter in place until the urine is clear is advisable. Preoperative use of finasteride or dutasteride has been suggested to help limit intraoperative and postoperative bleeding. A minimum of 2 weeks of therapy is needed for this potential benefit. The medication can be stopped once the catheter is removed, the patient is voiding well, and any gross hematuria has resolved.

Prolonged catheter drainage

The second complication is prolonged catheter drainage. Most patients need to be catheterized for 5-7 days. Muschter et al report a mean catheterization time of 18.3 days, but this report was conducted with older technology. Currently, physicians are prescribing patients alpha-adrenergic blockers to shorten the catheterization period. Re-evaluate patients who still cannot void after 4 weeks because they most likely cannot void spontaneously. If the patient originally had a severely atonic bladder, the situation may be permanent. Persistent retention may be managed with a repeat laser procedure, TURP, or continued catheter drainage.

Other complications

Other potential problems include urinary tract infection, epididymitis from prolonged catheter drainage, or a urethral stricture from the catheter. Muschter et al reported an initial series of 239 patients with a stricture rate of 3.8% and bladder neck contracture in 1.7%. Persistent obstruction caused a re-treatment rate of 9.6%.

In a more recent series of 112 men that used newer technology, Muschter et al report no major complications, but 3 (2.7%) patients required reoperation.¹¹

Arai (1996) reported no serious treatment-related complications in a 3-month study of 50 patients.¹²

Troublesome complications occurred in 12.6% of patients who reported irritative symptoms. Although urgency or stress incontinence can occur early in the postoperative period, no reports show sustained incontinence or prolonged irritative symptoms.

Proper selection of patients and increased experience with this technique has demonstrated that the procedure is safe with few major complications. Significant bleeding occurs in less than 2% of patients, retrograde ejaculation occurs in 15%, and strictures or bladder neck contracture occurs in 1%.

Outcome and Prognosis

Reports show that a major benefit of the interstitial laser coagulation (ILC) procedure is the retention of sexual function. Approximately 0-11.9% of patients report retrograde ejaculation, as compared to almost 100% of men who are treated with a TURP. In a group of 239 men treated with ILC, Muschter and Hofstetter report a 7% incidence of postoperative retrograde ejaculation in 163 sexually active men. Arai (1996) found a 4% incidence of new retrograde ejaculation,¹² and Muschter et al report a 6% incidence in a multicenter trial.

This procedure has been performed for more than 10 years. Muschter and Hofstetter reported the largest single institutional experience using an earlier interstitial laser system. Their study of 239 patients concluded that their patients had significant clinical improvement in symptoms, which correlates with objective changes in voiding during a 12-month follow-up study. The mean preoperative peak urine flow for this group was 7.7 mL/s, which improved to 16.3 mL/s at 3 months and improved slightly at 6 and 12 months to 17.9 mL/s and 17.8 mL/s, respectively.

Postvoid residuals decreased from a mean of 151 mL before surgery to 32 mL at 3 months, 28 mL at 6 months, and 29 mL at 12 months. The AUA symptom score presents a decrease from 25.4 originally to 8.1 at 3 months and 6.6 at both 6 and 12 months. Prostate volumes, as determined by transrectal ultrasound, show a decrease at an average of 32%.

Using the current indigo diode interstitial delivery system, with an 830-nm probe, Muschter reports on the 6-month outcomes of 112 men in a multicenter trial. Mean AUA symptom scores show a decline from 20.9 to 7.9, residual urine decrease from 105 to 38 mL, and peak flow rate improvement from 8-14.2 mL/s.

In a more recent trial, researchers randomly performed ILC or TURP on a group of patients. Comparing the preliminary results in 78 men treated with ILC to 59 receiving a TURP, both groups show significant improvement in voiding, but the TURP patients present the best voiding outcomes. At 6 months after surgery, the TURP group shows an AUA symptom score of 6 compared to 9.5 for the ILC patients. Peak flow rates are 19.4 mL/s for the TURP patients and 14.1 mL/s for ILC patients.

Arai et al (1996) reported 3-month outcome results on 50 patients. Mean AUA symptom scores show a decrease from 20.1 to 10.0, a postvoid residual urine volumes decrease from 90 mL to 45 mL, and a peak flow rate improvement from 7.0-9.5 mL/s. Arai et al report no significant complications and a rate of 80% of the patients expressing treatment satisfaction.¹²

In the short term, patients seem to tolerate the procedure very well and report satisfaction with the procedure. Few studies directly compare ILC in a prospective randomized manner to other forms of laser surgery. This is true of most of the newer technologies, which makes comparisons difficult.

In the longer term, re-treatment rates will be important. For TURP, re-treatment rates are about 20%. No reason exists to believe that ILC will be any better, except that ILC may be used in older, more fragile men with shorter life spans.

Future and Controversies

Urologists have a variety of procedures and medications that they can use to manage patients with symptoms and findings associated with benign prostatic hyperplasia (BPH). Physicians usually start patients on medications once they decide to initiate therapy. If patients respond poorly to pharmacologic therapy, some type of interventional therapy is appropriate.

The decision as to which type of intervention would best suit the patient depends upon the patient's situation, his medical condition, the size of his prostate, and the familiarity of the urologist with the various procedures. Most urologists are highly skilled in performing a TURP, which is likely to provide immediate relief of symptoms for a long period. Careful selection of the most appropriate procedure requires careful patient assessment and patient consultation regarding various alternatives.

Various new and competing technologies have been developed. These include thermotherapies such as microwave, heated water (WIT), radiofrequency tissue ablation, laser vaporization of the prostate, holmium laser resection, and high-intensity focused ultrasound.

Clinicians and patients benefit from the availability of an assortment of therapies. Thus far, no studies have been conducted with direct comparisons between these modalities.

Interstitial laser coagulation (ILC) offers a safe, effective, and relatively easy-to-learn technology for surgical treatment of BPH. Voiding is significantly improved and symptoms are reduced, but they are not comparable with the results achieved with transurethral resection electrocautery and some other laser techniques. ILC is associated with minimal morbidity but may have no advantage over free-beam lasers. The need for prolonged catheter drainage and the occurrence of postoperative irritative symptoms are similar with other treatments, although some of the current devices used for microwave thermotherapy eliminate the need for a catheter. The same is true for laser ablation. Most patients can leave without an indwelling catheter.

No immediate tissue loss is associated with ILC, and preservation of the urethra minimizes the tissue slough associated with free-beam laser techniques. Coagulated tissue is resorbed, but the reduction in prostate volume is less than that observed with other techniques. This reduction may correlate with the re-treatment rates, which appear higher than some other laser methods.

Multimedia

Media file 1: Benign prostatic hyperplasia. The prostate is located at the apex of the bladder and surrounds the proximal urethra.

Media file 2: Benign prostatic hyperplasia (BPH) diagnosis and treatment algorithm.

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Keywords

interstitial laser coagulation, ILC, indigo laser prostatectomy, interstitial laser prostatectomy, microwave thermotherapy, PPV laser prostatectomy, green light laser, holmium laser prostatectomy, HoLaP, high-intensity focused ultrasound, HIFU

Contributor Information and Disclosures

Author

Stanley A Brosman, MD, Clinical Professor, Department of Urology, University of California at Los Angeles Medical School
Stanley A Brosman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for Cancer Research, American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Clinical Oncology, American Urological Association, Association of Clinical Research Professionals, International Society of Urological Pathology, Société Internationale d'Urologie (International Society of Urology), Society for Basic Urologic Research, Society of Surgical Oncology, Society of Urologic Oncology, and Western Section American Urological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

Clinical trials

Phase 1 Study of the Litx™ BPH System in Patients With Lower Urinary Tract Symptoms (LUTS) Due to Benign Prostatic Hyperplasia (BPH)

PROLIEVE® Post-Marketing Study TREATMENT OF BENIGN PROSTATIC HYPERPLASIA (BPH)

Trial of the Safety and Efficacy of Ozarelix in Patients With Benign Prostatic Hyperplasia (BPH)

Study of Light-Activated Talaporfin Sodium in Patients With Lower Urinary Tract Symptoms (LUTS) Due to Benign Prostatic Hyperplasia (BPH)

Clinical Evaluation of NX-1207 for the Treatment of Benign Prostatic Hyperplasia (BPH) NX02-0018

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