eMedicine Specialties > Urology > Benign Prostatic Hypertrophy
Transurethral Microwave Thermotherapy of the Prostate (TUMT): Treatment
Updated: Feb 6, 2008
Treatment
Medical Therapy
Alpha-blockers
Alpha-blockers are a first-line treatment in patients with lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH). Nonselective alpha-blockers such as phenoxybenzamine improve obstructive symptoms and urinary flow but are not used because of significant adverse effects (eg, hypotension, retrograde ejaculation). Long-lasting oral nonspecific alpha1-blockers, such as terazosin, doxazosin, and alfuzosin, and the specific alpha1a-blocker tamsulosin improve symptoms in 30-75% of patients and increase urinary flow in 50%. When evaluating trials of alpha-blockers in patients with BPH, it must be remembered that a significant placebo response occurs in randomized studies; thus, study results should be interpreted with caution.
5-Alpha reductase inhibitors
The primary hormone implicated in prostatic growth is DHT, which is formed from testosterone by the enzyme 5-alpha reductase. Finasteride and dutasteride block 5-alpha reductase, decreasing the size of the prostate and prostate vascularity. The main effect is a decreased risk of urinary retention and BPH-related surgery, which is less impressive in persons with smaller glands.
Phytotherapy
Several over-the-counter and herbal remedies are available for prostatism, many of which have estrogenic or antitestosterone properties. Studies have shown some beneficial effect on patient symptoms, but questions regarding adverse effects, purity, and true effectiveness remain.
Surgical Therapy
Urethral stent
The placement of a urethral stent is a simple alternative in patients with BPH. While placement usually requires only minimal anesthesia, the failure rate is high and more than one third of urethral stents are eventually removed, some with difficulty. Therefore, this should be used with caution.
Transurethral resection of the prostate
The criterion standard for treatment of BPH is TURP. Improvement in voiding symptoms is reportedly 80-90% at 1 year and 60-75% at 5 years. Over this same period, only 5% of patients reportedly needed a repeat resection. Unfortunately, TURP requires general, spinal, or epidural anesthesia, and potential risks include bleeding and absorption of hypoosmotic irrigating fluids, which can cause hyponatremia, hypertension, and mental status changes. Long-term complications include incontinence (2-4%), urethral strictures (2-20%), and impotence (4.5-30%). The costs of the procedure are high because of operating-room time, surgeon time, and hospital stay. See Transurethral Resection of the Prostate for a full description of TURP.
Preoperative Details
In preparation for transurethral microwave thermotherapy (TUMT), patients need to be counseled about the risks, benefits, alternatives, and expected results of the therapy. Specific protocols and manufacturer guidelines differ per TUMT machine and must be meticulously followed. All patients receive appropriate preprocedure antimicrobial therapy, and an appropriate oral analgesic (eg, ibuprofen, ketorolac, morphine) and an anxiolytic (eg, benzodiazepine) may be preadministered. The penis is prepared with an antiseptic solution, and the urethra is anesthetized with 10-20 mL of 1-2% lidocaine gel. The treatment catheter is then positioned properly per guidelines. A rectal probe to monitor temperature (if used) is inserted, and the treatment program is started.
Intraoperative Details
Several machines are currently in use in the United States. Some of the more common machines are the Targis and Prostatron (Urologix; Minneapolis, Minn), TherMatrx Dose-Optimized Thermotherapy system (AMS; Minnetonka, Minn), Urowave (Dornier MedTech; Kennesaw, Ga), Prolieve system (Boston Scientific; Natick, Mass), and the ProstaLund CoreTherm (ProstaLund Operations AB; Lund, Sweden; marketed by ACMI). Each machine has its own specifics and guidelines for treatment.
For example, the Targis system is a small portable machine that delivers power from 0-60 W at a frequency of 902-928 MHz. The 21F catheter contains either a 2.8-cm or a 3.5-cm helical bipolar antenna (see Image 2) that provides impedance matching with the prostatic tissue so that thermal energy is delivered with minimal antennae self-heating; the shape of the antenna allows preferential heating at the anterolateral prostate. The rectal thermosensing unit (see Image 3) is composed of a balloon with 5 thermosensors that continuously monitors the rectal temperature and provides an automatic shut-down mechanism if rectal temperatures reach 42.5°C (108.5°F).
High prostate-tissue temperatures of 60-80°C (140-176°F) persist throughout therapy while a urethral coolant circulates at 8°C (46.4°F) to maintain the urethral temperature at 39-41°C (102.2-105.8°F), which is estimated by maintaining the rectal temperature below 42°C (107.6°F). The device decreases the power in 1-W increments when the rectal temperature reaches 42°C (107.6°F) and in 3-W increments if no response occurs. While the procedure originally took 60 minutes to complete, newer software and catheters (eg, Cooled ThermoCath, Urologix) are now available that provide equal outcomes in only 28.5 minutes.
In contrast, the Prostatron is a larger machine that uses a monopolar rather than bipolar antenna. The initial software program, Prostasoft 2.0, was a low-energy protocol with maximum energy of 60 W; treatment took 60 minutes, and noticeable symptomatic but not objective improvement occurred. The higher-energy Prostasoft 2.5 allowed a stepwise increase in energy without interruptions to achieve intraprostatic temperatures of 75°C (167°F) and used urethral cooling with 20°C (68°F) water. The treatment similarly took 60 minutes, and results were better than with the initial software.
The most current and most powerful software is Prostasoft 3.5. Only 30 minutes of treatment is required. Compared with Prostasoft 2.5, patients report a slightly higher level of pain early in the treatment due to the initial higher power, but, eventually, the same level of comfort is achieved. This protocol is associated with a slightly higher rate of postprocedure urinary retention.
Many of the other systems work similarly overall, with minor alterations. For example, the ProstaLund contains intraprostatic thermosensors to monitor temperatures, the Urowave applicator enlarges during treatment to ensure maximal urethral contact, and the Prolieve system includes a 46F dilating balloon as part of the treatment protocol. During any TUMT procedure, patients may experience mild perineal warmth, mild pain, and a sense of urinary urgency. Rarely is pain significant enough to require stopping the therapy. Most patients do require some oral analgesics during treatment.
Several different TUMT machines are commercially available, and the protocol for the specific machine must be followed per the manufacturer's guidelines.
Postoperative Details
Prostatic edema is expected after microwave therapy, leading to a risk of urinary retention, especially with higher-energy protocols. Early studies on several low-energy protocols reported a 6-36% need for indwelling catheterization for up to 1 month, while 10% of patients undergoing high-energy protocols require catheterization for more than 3 months. Patients with larger prostates are more prone to long-term catheterization because of increased edema. Therefore, many protocols suggest leaving a catheter in for a few days to 2 weeks in all patients.
A slow process of improvement in urinary flow is characteristic of high-energy TUMT. Coagulated tissue must be absorbed, and the treated area must be reorganized before sufficient voiding is achieved. Patients may notice an improvement over a period of many months.
Patients maintained on alpha-blockers after TUMT may experience fewer urinary symptoms and have a decreased incidence of retention. Other protocols suggest placing a temporary prostatic bridge catheter to prevent prostatic obstruction immediately after TUMT. Proponents of the bridge catheter describe a potentially decreased incidence of urinary tract infection compared with an indwelling catheter or clean intermittent catheterization and a better immediate peak flow rate, symptom score, and quality of life compared with not using a bridge catheter.
Follow-up
Patients should return to the clinic for follow-up. If a catheter is placed, it can be removed at home or in the clinic. All patients should be instructed to watch for an inability to void, painful voiding, high fevers, abdominal pain, or other problems. Posttreatment convalescence is relatively rapid, with most patients able to void and a mean recovery time of less than 5 days at home. This suggests that some patients return to full activity relatively early.
For excellent patient education resources, visit eMedicine's Prostate Health Center. Also, see eMedicine's patient education article Enlarged Prostate.
Complications
The main risks of transurethral microwave thermotherapy (TUMT) include urinary retention, infection, and postoperative pain. One report cited a 13% risk of infection, 11% risk of retention, and 3% rate of acute incontinence. Patients undergoing TUMT are at an increased risk for urinary tract infections compared with TURP, possibly due to necrotic tissue sloughing or to a catheter left indwelling for a longer duration.
While changes in sexual function due to the role of the prostate, bladder neck, and local neural tissue are observed with all forms of benign prostatic hypertrophy (BPH), the overall reported rate of changes in sexual function is 17% with TUMT compared with 36% with TURP. Retrograde ejaculation is observed in 48-90% of patients after TURP and in 0-28% of patients after TUMT. However, this appears to be a trade-off for better urinary flow patterns after TURP than after TUMT.
Erectile dysfunction is observed after any treatment for BPH. Newly onset or worsening erectile dysfunction after TUMT is uncommon if a patient previously had normal erections. Although causes have not been fully elucidated, psychogenic factors, bladder neck trauma, and neurogenic voiding dysfunction probably play roles. Lower-energy TUMT protocols appear to yield a lower incidence of erectile dysfunction compared with higher-energy protocols, but this occurs at the expense of better urinary results. In 1997, Francisca et al reported no change in sexual performance after low-energy TUMT compared with a sham procedure in 147 patients3 , while, in 2000, Arai et al reported an 18.2% rate of erectile dysfunction after TUMT using a high-energy protocol.4
Overall, patients' satisfaction with their sex lives seems to be higher among those who have undergone TUMT rather than TURP, with 55% of patients undergoing microwave thermotherapy reported as being very satisfied, compared with a 21% rate among patients after TURP. However, only 27% of this population is satisfied with their urinary flow after TUMT, compared with 74% of patients who are satisfied after TURP.
The risk of acute myocardial infarction is not negligible using TUMT. A 3.9-year follow-up study compared 888 TURP patients with 478 TUMT patients; both treatments were associated with a higher incidence of acute myocardial infarction, especially more than 2 years after therapy. More patients died from cardiovascular disease after both therapies than in the general population.
Various other rare complications have been reported following TUMT. These include, but are not limited to, urethrorectal fistula, bladder perforation, bowel irradiation, chronic pain, urethral injury, prostatitis, a pressure sensation, urinary urgency, urethral tear, anal irritation, urethral stricture, infertility, and retrograde ejaculation. Proper intratreatment physician and nursing observation are vital to decrease these risks.
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 |
| « Previous Page | Next Page » |
References
Yerushalmi A, Fishelovitz Y, Singer D, Reiner I, Arielly J, Abramovici Y, et al. Localized deep microwave hyperthermia in the treatment of poor operative risk patients with benign prostatic hyperplasia. J Urol. May 1985;133(5):873-6. [Medline].
Khair AA, Pacelli A, Iczkowski KA, Cheng L, Corica FA, Larson TR, et al. Does transurethral microwave thermotherapy have a different effect on prostate cancer than on benign or hyperplastic tissue?. Urology. Jul 1999;54(1):67-72. [Medline].
Francisca EA, d'Ancona FC, Hendriks JC, Kiemeney LA, Debruyne FM, de la Rosette JJ. Quality of life assessment in patients treated with lower energy thermotherapy (Prostasoft 2.0): results of a randomized transurethral microwave thermotherapy versus sham study. J Urol. Nov 1997;158(5):1839-44. [Medline].
Arai Y, Aoki Y, Okubo K, Maeda H, Terada N, Matsuta Y, et al. Impact of interventional therapy for benign prostatic hyperplasia on quality of life and sexual function: a prospective study. J Urol. Oct 2000;164(4):1206-11. [Medline].
de la Rosette JJ, Francisca EA, Kortmann BB, Floratos DL, Debruyne FM, Kiemeney LA. Clinical efficacy of a new 30-min algorithm for transurethral microwave thermotherapy: initial results. BJU Int. Jul 2000;86(1):47-51. [Medline].
Alivizatos G, Ferakis N, Mitropoulos D, Skolarikos A, Livadas K, Kastriotis I. Feedback microwave thermotherapy with the ProstaLund Compact Device for obstructive benign prostatic hyperplasia: 12-month response rates and complications. J Endourol. Jan-Feb 2005;19(1):72-8. [Medline].
Blute ML, Tomera KM, Hellerstein DK, McKiel CF Jr, Lynch JH, Regan JB, et al. Transurethral microwave thermotherapy for management of benign prostatic hyperplasia: results of the United States Prostatron Cooperative Study. J Urol. Nov 1993;150(5 Pt 2):1591-6. [Medline].
Bolt JW, Evans C, Marshall VR. Sexual dysfunction after prostatectomy. Br J Urol. Apr 1987;59(4):319-22. [Medline].
Brehmer M, Svensson I. Heat-induced apoptosis in human prostatic stromal cells. BJU Int. Mar 2000;85(4):535-41. [Medline].
Bruskewitz R, Issa MM, Roehrborn CG, Naslund MJ, Perez-Marrero R, Shumaker BP, et al. A prospective, randomized 1-year clinical trial comparing transurethral needle ablation to transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia. J Urol. May 1998;159(5):1588-93; discussion 1593-4. [Medline].
Chiou RK, Chen WS, Akbari A, et al. Long-term outcome of prostatic stent treatment for benign prostatic hyperplasia. Urology. Oct 1996;48(4):589-93. [Medline].
d'Ancona FC, Albers YH, Kiemeney LA, Xue Y, Smedts F, van der Poel HG, et al. Can histopathology predict treatment outcome following high-energy transurethral microwave thermotherapy of the prostate? Results of a biopsy study. Prostate. Jun 15 1999;40(1):28-36. [Medline].
d'Ancona FC, Francisca EA, Hendriks JC, Debruyne FM, de la Rosette JJ. How to select patients for high-energy transurethral microwave thermotherapy. Urology. Jan 1999;53(1):111-7. [Medline].
D'Ancona FC, van der Bij AK, Francisca EA, Kho H, Debruyne FM, Kiemeney LA, et al. Results of high-energy transurethral microwave thermotherapy in patients categorized according to the American Society of Anesthesiologists operative risk classification. Urology. Feb 1999;53(2):322-8. [Medline].
David RD, Grunberger I, Shore N, Swierzewski SJ 3rd. Multicenter initial U.S. experience with CoreTherm-monitored feedback transurethral microwave thermotherapy for individualized treatment of patients with symptomatic benign prostatic hyperplasia. J Endourol. Sep 2004;18(7):682-5. [Medline].
de la Rosette JJ, D'Ancona FC, Debruyne FM. Current status of thermotherapy of the prostate. J Urol. Feb 1997;157(2):430-8. [Medline].
DiSantostefano RL, Biddle AK, Lavelle JP. The long-term cost effectiveness of treatments for benign prostatic hyperplasia. Pharmacoeconomics. 2006;24(2):171-91. [Medline].
Djavan B, Bursa B, Basharkhah A, Seitz C, Remzi M, Ghawidel K, et al. Pretreatment prostate-specific antigen as an outcome predictor of targeted transurethral microwave thermotherapy. Urology. Jan 2000;55(1):51-7. [Medline].
Djavan B, Roehrborn CG, Shariat S, Ghawidel K, Marberger M. Prospective randomized comparison of high energy transurethral microwave thermotherapy versus alpha-blocker treatment of patients with benign prostatic hyperplasia. J Urol. Jan 1999;161(1):139-43. [Medline].
Djavan B, Shariat S, Fakhari M, Ghawidel K, Seitz C, Partin AW, et al. Neoadjuvant and adjuvant alpha-blockade improves early results of high-energy transurethral microwave thermotherapy for lower urinary tract symptoms of benign prostatic hyperplasia: a randomized, prospective clinical trial. Urology. Feb 1999;53(2):251-9. [Medline].
Eisenberg ER, Badlani GH. Long-term treatment outcomes of CoreTherm microwave feedback thermotherapy. Curr Urol Rep. Aug 2004;5(4):287-94. [Medline].
Eliasson T, Damber JE, Terio H. Pressure-flow studies before and after transurethral microwave thermotherapy of benign prostatic hyperplasia using low- and high-energy protocols. Br J Urol. Oct 1998;82(4):513-9. [Medline].
Eliasson T, Wagrell L. New technologies for the surgical management of symptomatic benign prostatic enlargement: tolerability and morbidity of high energy transurethral microwave thermotherapy. Curr Opin Urol. Jan 2000;10(1):15-7. [Medline].
Ferakis N, Skolarikos A, Staios D, Liakouras C, Alivizatos G. Treatment characteristics and inherent prostatic features do not predict patient outcome after high-energy transurethral thermotherapy: a prospective study of prostalund feedback treatment. J Endourol. Dec 2006;20(12):1075-81. [Medline].
Floratos DL, Sonke GS, Francisca EA, Kiemeney LA, Kortmann BB, Debruyne FM, et al. High energy transurethral microwave thermotherapy for the treatment of patients in urinary retention. J Urol. May 2000;163(5):1457-60. [Medline].
Francisca EA, Kortmann BB, Floratos DL, Kiemeney LA, Debruyne FM, de la Rosette JJ. Tolerability of 3.5 versus 2.5 high-energy transurethral microwave thermotherapy. Eur Urol. Jul 2000;38(1):59-63. [Medline].
Gravas S, Laguna P, Ehrnebo M, Wagrell L, Mattiasson A, de la Rosette JJ. Seeking evidence that cell kill guided thermotherapy gives results not inferior to those of transurethral prostate resection: results of a pooled analysis of 3 studies of feedback transurethral microwave thermotherapy. J Urol. Sep 2005;174(3):1002-6; discussion 1006. [Medline].
Hahn RG, Farahmand BY, Hallin A, Hammar N, Persson PG. Incidence of acute myocardial infarction and cause-specific mortality after transurethral treatments of prostatic hypertrophy. Urology. Feb 2000;55(2):236-40. [Medline].
Hallin A, Berlin T. Transurethral microwave thermotherapy for benign prostatic hyperplasia: clinical outcome after 4 years. J Urol. Feb 1998;159(2):459-64. [Medline].
Hanbury DC, Sethia KK. Erectile function following transurethral prostatectomy. Br J Urol. Jan 1995;75(1):12-3. [Medline].
Herrmann TR, Gross AJ, Schultheiss D, Kaufmann PM, Jonas U, Burchardt M. Transurethral microwave thermotherapy for the treatment of BPH: still a challenger?. World J Urol. Sep 2006;24(4):389-96. [Medline].
Hoffman RM, MacDonald R, Monga M, Wilt TJ. Transurethral microwave thermotherapy vs transurethral resection for treating benign prostatic hyperplasia: a systematic review. BJU Int. Nov 2004;94(7):1031-6. [Medline].
Huidobro C, Bolmsjo M, Larson T, de la Rosette J, Wagrell L, Schelin S, et al. Evaluation of microwave thermotherapy with histopathology, magnetic resonance imaging and temperature mapping. J Urol. Feb 2004;171(2 Pt 1):672-8. [Medline].
Kellner DS, Armenakas NA, Brodherson M, Heyman J, Fracchia JA, et al. Efficacy of high-energy transurethral microwave thermotherapy in alleviating medically refractory urinary retention due to benign prostatic hyperplasia. Urology. Oct 2004;64(4):703-6. [Medline].
Larson TR, Collins JM, Corica A. Detailed interstitial temperature mapping during treatment with a novel transurethral microwave thermoablation system in patients with benign prostatic hyperplasia. J Urol. Jan 1998;159(1):258-64. [Medline].
Naslund MJ. Transurethral needle ablation of the prostate. Urology. Aug 1997;50(2):167-72. [Medline].
Nørby B, Frimodt-Møller PC. Development of a urethrorectal fistula after transurethral microwave thermotherapy for benign prostatic hyperplasia. BJU Int. Mar 2000;85(4):554-5. [Medline].
Parikh AM, Milroy EJ. Precautions and complications in the use of the urolume wallstent. Eur Urol. 1995;27(1):1-7. [Medline].
Ramsey EW, Miller PD, Parsons K. A novel transurethral microwave thermal ablation system to treat benign prostatic hyperplasia: results of a prospective multicenter clinical trial. J Urol. Jul 1997;158(1):112-8; discussion 118-9. [Medline].
Rodrigues Netto N Jr, Claro Jde A, Cortado PL. Ejaculatory dysfunction after transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia. J Endourol. Jun 1994;8(3):217-9. [Medline].
Roehrborn CG, Preminger G, Newhall P, Denstedt J, Razvi H, Chin LJ, et al. Microwave thermotherapy for benign prostatic hyperplasia with the Dornier Urowave: results of a randomized, double-blind, multicenter, sham-controlled trial. Urology. Jan 1998;51(1):19-28. [Medline].
Sapozink MD, Boyd SD, Astrahan MA, Jozsef G, Petrovich Z. Transurethral hyperthermia for benign prostatic hyperplasia: preliminary clinical results. J Urol. May 1990;143(5):944-9; discussion 949-50. [Medline].
Schiavi RC, Rehman J. Sexuality and aging. Urol Clin North Am. Nov 1995;22(4):711-26. [Medline].
Tan AH, Nott L, Hardie WR, Chin JL, Denstedt JD, Razvi H. Long-term results of microwave thermotherapy for symptomatic benign prostatic hyperplasia. J Endourol. Dec 2005;19(10):1191-5. [Medline].
Thalmann GN, Graber SF, Bitton A, Burkhard FC, Gruenig O, Studer UE. Transurethral thermotherapy for benign prostatic hyperplasia significantly decreases infravesical obstruction: results in 134 patients after 1 year. J Urol. Aug 1999;162(2):387-93. [Medline].
Vesely S, Knutson T, Damber JE, Dicuio M, Dahlstrand C. TURP and low-energy TUMT treatment in men with LUTS suggestive of bladder outlet obstruction selected by means of pressure-flow studies: 8-year follow-up. Neurourol Urodyn. 2006;25(7):770-5. [Medline].
Wagrell L, Schelin S, Nordling J, Richthoff J, Magnusson B, Schain M, et al. Three-year follow-up of feedback microwave thermotherapy versus TURP for clinical BPH: a prospective randomized multicenter study. Urology. Oct 2004;64(4):698-702. [Medline].
Walmsley K, Kaplan SA. Transurethral microwave thermotherapy for benign prostate hyperplasia: separating truth from marketing hype. J Urol. Oct 2004;172(4 Pt 1):1249-55. [Medline].
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
