eMedicine Specialties > Urology > Benign Prostatic Hypertrophy

Transurethral Microwave Thermotherapy of the Prostate (TUMT): Workup

Author: Jonathan Rubenstein, MD, Staff Physician, Department of Urology, University of California, San Francisco
Coauthor(s): Kevin T McVary, MD, Associate Professor, Department of Urology, Northwestern University Medical School
Contributor Information and Disclosures

Updated: Feb 6, 2008

Workup

Laboratory Studies

  • CBC count
    • A CBC count is not required before transurethral microwave thermotherapy (TUMT) but stratifies patient risks.
    • A platelet count and platelet function studies should be performed if patient history and/or physical examination suggests a qualitative or quantitative platelet deficiency.
  • Serum chemistries
    • All patients should be evaluated for renal insufficiency and electrolyte abnormalities.
    • Those with a baseline creatinine level greater than 1.7 mg/dL due to obstruction should be considered for methods other than TUMT, such as TURP or open enucleation.
  • Prostate-specific antigen
    • Serum prostate-specific antigen (PSA) levels may be measured to help determine if a patient is at risk for prostate cancer.
    • If clinically indicated or suspected, a prostate biopsy should be performed.
    • Patients with a higher PSA level at baseline without cancer may actually respond more favorably to TUMT than those with lower PSA levels, for unknown reasons.
  • Urinalysis and/or urine culture and sensitivities: All patients must be free of urinary tract infection prior to TUMT.

Imaging Studies

  • Transrectal ultrasonography
    • Transrectal ultrasonography is suggested before performing TUMT to evaluate prostate size and to evaluate for prostatic pathology.
    • Patients with prostate volumes estimated to be less than 30 mL or greater than 100 mL respond less favorably to TUMT than those with moderately sized glands; consider other therapies for these patients.
  • Renal ultrasonography
    • Renal ultrasonography is noninvasive, provides information about renal anatomy, and may demonstrate pathology.
    • Patients should undergo renal ultrasonography to evaluate for hydronephrosis due to bladder outlet obstruction if they have a history of urinary retention or have an elevated creatinine level.
    • Patients with hematuria may also benefit from renal ultrasonography to evaluate for renal parenchymal pathology, especially if intravenous pyelography or CT scanning is contraindicated.

Other Tests

  • Voiding velocity
    • The voiding velocity is a noninvasive but nonspecific electronic recording of urinary flow rate.
    • Patients void into a specially designed funnel that contains an electronic sensor that records urine volume and velocity and plots it against time. Results include a peak flow rate, average flow rate, and total volume voided. This information is not used to evaluate detrusor contractility. Voiding velocity can be used to monitor response to treatment.
    • For accuracy, the patient should void at least 125-150 mL. Because of variations among voids, a minimum of 2 voids should be collected.
    • Other causes of a slow stream may include inadequate detrusor contraction or other causes of bladder outlet obstruction.
    • A man without evidence of obstruction should have an average velocity of 12 mL/s and an average peak velocity of 20 mL/s.
    • Patients with initially lower flow rates may respond better to TUMT than those with higher rates if their detrusor function is normal.
  • Symptom score
    • Symptom scores, such as the International Prostate Symptom Score (IPSS), are commonly used to quantify symptoms and to monitor the response to treatment.
    • Studies have failed to document a strong correlation between symptom scores and physiologic changes due to benign prostatic hypertrophy (BPH).
    • Patients may have minimal voiding symptoms that may interfere significantly with the quality of life; conversely, they may have significant voiding symptoms that may not interfere significantly with quality of life.
  • Postvoid residual
    • The postvoid residual (PVR), the volume of urine remaining immediately after micturition, is measured with urinary catheterization or ultrasonography.
    • Patients usually void to completion; however, those with neurogenic bladder or bladder decompensation due to chronic outlet obstruction may retain significant quantities of urine.
    • The PVR does not necessarily correlate with signs and symptoms of prostatism and does not predict surgical outcome.
    • Patients with a higher PVR have slightly higher rates of failure of watchful waiting, and they are at an increased risk of complications such as urinary tract infections and renal failure.

Diagnostic Procedures

  • Cystourethroscopy
    • All patients considered for TUMT should undergo cystoscopy to rule out urethral stricture, to evaluate for the presence of bladder or urethral pathology, to measure prostatic urethral length, and to evaluate prostatic lobe (especially median lobe) size.
    • Patients with lateral lobe hypertrophy respond much better to TUMT than those with median lobe hypertrophy or a median bar.
  • Pressure-flow study
    • A pressure-flow study simultaneously measures the bladder pressure and flow rate during voiding. It can be performed through a urethral or suprapubic urinary catheter.
    • Candidates include patients whose voiding velocity and postvoid residual measurements are not sufficient to determine whether poor flow is due to bladder outlet obstruction or due to poor detrusor contraction, such as patients with neurologic disease or detrusor failure.
  • Cystometrography
    • Cystometrography (CMG) involves the measurement of bladder pressures during filling. Patients are awake and respond to the sensation of filling with a verbal response to the examiner.
    • Generally, liquids (eg, water, normal saline, contrast) are used for bladder filling, although some use gases (eg, carbon dioxide).
    • Cystometrography evaluates bladder capacity, the presence or absence of uninhibited detrusor contractions, and estimated bladder compliance. While this may add little information in routine cases, it may be of value in patients with known or suspected neurological impairment.
    • Patients who have adequate bladder contractions have better outcomes after TUMT than those with poor detrusor contractions.
  • Urethral pressure profile: A urethral pressure profile test measures pressures along the length of the urethra. In patients with known or suspected urethral obstruction, this test helps determine the location of the lesion. This is not necessary in most cases.
  • Video urodynamics
    • Video urodynamics involves performing cystometrography or a penile flow study under fluoroscopic guidance using contrast as the filling medium, yielding anatomic information in addition to pressure information.
    • Video urodynamics should be reserved for complex cases (eg, patients with neurogenic bladder or incontinence) or for cases in which a specific sites of obstruction need to be identified.

Histologic Findings

Unlike with TURP or open prostatectomy, no histological specimen is obtained with TUMT. Patients with a PSA level within the reference range and negative prior prostatic biopsy findings may still be at risk for clinically silent prostate cancer.

Few studies have evaluated the histologic effect of TUMT on prostatic tissue in vivo. Khair et al performed radical prostatectomies after TUMT in 9 patients with prostate cancer—7 within 1 week, and 2 more than 1 year later.2 At 1 week, hemorrhagic necrosis and devitalized tissues without inflammation were observed, with necrosis seen in benign, stromal, and cancerous areas without skips. The mean volume of necrosis was 8.8 mL, and the average amount of necrosis was 22%. One year later, only nonspecific chronic inflammation and desquamated metaplasia with evidence of periurethral fibrosis occurred. The mean volume of necrosis remaining was 0.2 mL, which was less than 1%, implying that cells were sloughed away. No differences were observed between BPH and cancerous elements.

More on Transurethral Microwave Thermotherapy of the Prostate (TUMT)

Overview: Transurethral Microwave Thermotherapy of the Prostate (TUMT)
Workup: Transurethral Microwave Thermotherapy of the Prostate (TUMT)
Treatment: Transurethral Microwave Thermotherapy of the Prostate (TUMT)
Follow-up: Transurethral Microwave Thermotherapy of the Prostate (TUMT)
Multimedia: Transurethral Microwave Thermotherapy of the Prostate (TUMT)
References
Further Reading
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References

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Further Reading

For additional information, visit Medscape’s BPH Resource Center.

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Keywords

transurethral microwave thermotherapy of the prostate, TUMT, hyperthermia, thermotherapy, thermoablation, benign prostatic hypertrophy, microwave therapy, prostatism, lower urinary tract symptoms, LUTS, BPH, transurethral resection of the prostate, TURP, Targis system, Targis machine, Prostasoft 2.0, Prostasoft 2.5, Prostasoft 3.5, open prostatic enucleation, open prostatectomy, adenomatous hyperplasia, nocturia, urinary frequency, urgency, dysuria, urinary tract infection, bladder stones, renal failure, hydronephrosis, microscopic hematuria, gross hematuria, neurogenic voiding dysfunction, urethral stricture, prostatitis, urinary bladder, high-energy transurethral microwave thermotherapy of the prostate, high-energy TUMT

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Contributor Information and Disclosures

Author

Jonathan Rubenstein, MD, Staff Physician, Department of Urology, University of California, San Francisco
Jonathan Rubenstein, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Coauthor(s)

Kevin T McVary, MD, Associate Professor, Department of Urology, Northwestern University Medical School
Kevin T McVary, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Andrology, American Urological Association, Chicago Medical Society, Illinois State Medical Society, and Society of Urologic Oncology
Disclosure: Nothing to disclose.

Medical Editor

Bradley Fields Schwartz, DO, FACS, Associate Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

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

Chief Editor

Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio
Stephen W Leslie, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, National Kidney Foundation, and Ohio State Medical Association
Disclosure: Nothing to disclose.

 
 
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