Benign prostatic hyperplasia (BPH) is not simply a case of too many prostate cells. Prostate growth involves hormones, occurs in different types of tissue (e.g., muscular, glandular), and affects men differently. As a result of these differences, treatment varies in each case. There is no cure for BPH and once prostate growth starts, it often continues, unless medical therapy is started. The prostate grows in two different ways. In one type of growth, cells multiply around the urethra and squeeze it, much like you can squeeze a straw. The second type of growth is middle-lobe prostate growth in which cells grow into the urethra and the bladder outlet area. This type of growth typically requires surgery.

Anatomy
The prostate is a walnut-sized gland located beneath the bladder and in front of the rectum. It is surrounded by a capsule of fibrous tissue called the prostate capsule. The urethra (tube that transports urine and sperm out of the body) passes through the prostate to the bladder neck. Prostate tissue produces prostate specific antigen and prostatic acid phosphatase, an enzyme found in seminal fluid (the milky substance that combines with sperm to form semen).

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It is difficult to establish incidence and prevalence of BPH because research groups often use different criteria to define the condition. According to the National Institutes of Health (NIH), BPH affects more than 50% of men over age 60 and as many as 90% of men over the age of 70.

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The cause of benign prostatic hyperplasia is unknown. It is possible that the condition is associated with hormonal changes that occur as men age. The testes produce the hormone testosterone, which is converted to dihydrotestosterone (DHT) and estradiol (estrogen) in certain tissues. High levels of dihydrotestosterone, a testosterone derivative involved in prostate growth, may accumulate and cause hyperplasia. How and why levels of DHT increase remains a subject of research.

BPH is a condition of aging. Nearly all men over the age of 50 have an enlarged prostate.

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Common symptoms of benign prostatic hyperplasia include the following:

• Blood in the urine (i.e., hematuria), caused by straining to void
• Dribbling after voiding
• Feeling that the bladder has not emptied completely after urination
• Frequent urination, particularly at night (i.e., nocturia)
• Hesitant, interrupted, or weak urine stream caused by decreased force
• Leakage of urine (i.e., overflow incontinence)
• Pushing or straining to begin urination
• Recurrent, sudden, urgent need to urinate

In severe cases of BPH, another symptom, acute urinary retention (the inability to urinate), can result from holding urine for a long time, alcohol consumption, long period of inactivity, cold temperatures, allergy or cold medications containing decongestants or antihistamines, and some prescription drugs (e.g., ipratropium bromide, albuterol, epinephrine). Any of these factors can prevent the urinary sphincter from relaxing and allowing urine to flow out of the bladder. Acute urinary retention causes severe pain and discomfort. Catheterization may be necessary to drain urine from the bladder and obtain relief.

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Minimally invasive BPH treatments use state-of-the-art tools and techniques to reduce or eliminate symptoms. Men are treated on an outpatient basis in a urologist's office or the hospital. Other advantages of minimally invasive treatments are:

• less pain
• faster recovery
• lower costs
• local anesthesia and mild sedative

Usually, heat is used to destroy excess prostate tissue. Techniques differ in heat source, heat delivery method, side effects, and number of treatments. Delivery methods include:

• Laser
  • Indigo
  • PVP
• Microwave
  • CoreTherm®
  • Cooled
  • ThermoTherapy™/TUMT™ TherMatrx®
• Other
  • AquaTherm™ System
  • TUNA
  • TUVP

Laser Treatments

Interstitial Laser Coagulation Interstitial laser coagulation is often performed under local anesthesia on an outpatient basis. The Indigo LaserOptic Treatment™ System uses a cystoscope through which a fiberoptic probe is directly introduced into the prostate. Heat energy is conducted through the probe for 3 minutes and quickly coagulates the obstructing prostate tissue. The process can be repeated to treat another area in the prostate, as determined by the physician. The procedure lasts approximately 30 to 60 minutes. Symptoms resolve over 6 to 12 weeks, as tissue is absorbed.

After the device is removed, a Foley catheter is inserted to drain urine for several days, until bladder function returns. Blood in the urine is a common side effect of the procedure and resolves within a week or so. Impotence, retrograde ejaculation, and incontinence are rare complications.

PVP
Photoselective vaporization of the prostate (PVP) is a minimally invasive procedure that uses a special high-energy laser to vaporize excess prostate tissue and seal the treated area. The procedure is performed on an outpatient basis in a hospital or surgical center and may be performed under local, spinal, or general anesthesia. PVP takes between 10 and 30 minutes to perform, depending on the size of the prostate and patients are usually discharged within a few hours.

The type of laser used in PVP is delivered to the prostate through an endoscope (device that consists of a tube and an optical system) that is inserted into the urethra. The procedure prevents damage to surrounding tissue and minimizes side effects such as pain, blood in the urine (hematuria), and swelling.

Many patients do not require a catheter after PVP, and those who do typically are catheterized for less than 24 hours. Patients are advised to avoid strenuous exercise for 2 weeks following the procedure and can usually resume regular activities the next day. PVP provides immediate and long-lasting results comparable with other minimally invasive procedures.

Microwave Treatment

Cooled ThermoTherapy™/TUMT™
Cooled ThermoTherapy™/TUMT™ reduces BPH symptoms, preserves sexual function, and provides durable results using the Targis™ system or the Prostatron® system. Treatment can be completed within 30 minutes, usually does not require anesthesia, and is performed in a physician’s office or an outpatient setting.

In this treatment, a specially designed antenna inside a catheter is inserted into the prostate through the urethra. This antenna is used to direct microwave energy into the prostate to heat and destroy enlarged tissue. During the procedure, cool water is circulated through the catheter to minimize patient discomfort, protect adjacent urethral tissues from excessive temperatures, and reduce the risk for serious side effects.

Medication is often administered to reduce discomfort and help patients relax during the procedure. Many patients are able to read, watch television, or listen to music during treatment and some may experience the following:

• Bladder spasms
• Pressure in the rectum
• Sensation of needing to empty the bladder or have a bowel movement
• Warm or burning sensation in the abdomen or penis

Following treatment, anti-inflammatory medication and antibiotics may be prescribed. Most patients can resume normal activity immediately after treatment. Destroyed prostatic tissue is reabsorbed by the body or discharged in the urine over the course of 6 to 12 weeks and BPH symptoms gradually improve during this time.

Side effects usually resolve without intervention within a few weeks of treatment and include the following:

• Frequent urination
• Pink discharge in the urine or around the catheter
• Soreness in the lower abdomen
• Urethral inflammation and swelling (most patients require catheterization for 2–5 days)
• Urgency (even after removal of the catheter)

CoreTherm®
An outpatient, microwave-generated heat treatment that destroys excess prostate tissue. CoreTherm uses a transurethral catheter containing a microwave antenna and an intraprostatic probe with three temperature sensors. This system takes into account the fact that different patients have differently sized prostates and different intraprostatic blood flows.

Continuous monitoring of intraprostatic temperatures, intraprostatic blood flow rate, progressive destruction of targeted tissue, and adjustable microwave power enable the physician to tailor treatment to the individual. These data are calculated and displayed in real time on a computer screen throughout the session, which helps the physician determine when to stop treatment.

Before the procedure, the bladder and bowel are emptied, and the patient is given a sedative, local anesthesia, and antibiotics. Urinary retention is a common temporary side effect. A urinary catheter is placed after treatment and removed within a couple of weeks.

TherMatrx®
TherMatrx® is a minimally invasive procedure performed in a urologist's office that uses heat delivered through a microwave antenna. This outpatient procedure requires local anesthesia. A mild sedative or pain reliever may be given to help the patient relax and make him as comfortable as possible during the procedure.

A urethral catheter containing the microwave antenna is passed through the urethra and prostate gland and is secured by a balloon at the tip of the catheter that passes through the uretheral sphincter. Localized microwave energy is delivered at a temperature high enough to relieve BPH symptoms, including difficult, frequent, or urgent urination. The procedure lasts approximately 1 hour.

Following the procedure, a catheter is inserted to drain urine from the bladder for a few days. Once the catheter is removed, the patient can resume normal activity. Symptoms improve in 4 to 6 weeks. Healing takes 6 weeks to 3 months.

Possible complications include incontinence, pain during urination, and urinary retention. Most complications resolve during the healing period without intervention.

OTHER

A catheter made up of four contiguous sections - the urinary drainage lumen, the positioning balloon, the treatment balloon, and the insulated shaft - is attached to a computer console that heats water to 60° C (140° F). Throughout the procedure, the computer console precisely maintains the water temperature at 60° C, and urine is allowed to pass by means of the urinary drainage lumen.

The urologist inserts the catheter through the urethra and into the bladder. Once the urinary drainage lumen and the positioning balloon reach the bladder, the positioning balloon inflates and secures the catheter. The treatment balloon, resting in the prostatic urethra (located directly below the bladder), inflates and fills with water. Temperature-controlled water circulates through the insulated shaft into the treatment balloon. The catheter conducts heat through the insulated shaft to the prostate gland, raises the temperature of the gland, and destroys the obstructive tissue. Destroyed tissue is either sloughed off or absorbed by the body over time. After 45 minutes of treatment, the catheter is removed.

Following the procedure, a urethral catheter remains in place for approximately 4 to 17 days, or until normal urinary flow is restored. Temporary hematuria, or blood in the urine, is usually present after the procedure, and treatable urinary tract infection or urinary urgency also may occur.

Transurethral Needle Ablation (TUNA)
Transurethral needle ablation of the prostate (TUNA), procedure delivers low level radio frequency (RF) energy to the prostate, relieving obstruction without causing damage to the urethra. A small probe is inserted through the urethra and into the prostate. Two small electrodes are deployed into the prostate and a low level of radio frequency energy is applied. The energy heats the prostate tissue and shrinks it, relieving the obstruction while protecting the urethra and surrounding areas.

The TUNA procedure can be performed in an office or hospital outpatient center in less than 1 hour using minimal anesthesia. Clinical studies have demonstrated that TUNA provides significant improvements in urine flow and other symptoms of BPH. Its long-term side effects are minor compared with those of such conventional procedures as TURP. Most patients are able to return to their normal activities within 24 hours.

Possible complications include blood in the urine, discomfort or pain during urination, urinary retention, and sexual dysfunction. Most complications resolve without intervention during the healing period.

TUVP
Transurethral vaporization of the prostate (TUVP), also called vaportrode, involves direct application of heat (under 100°F) to the prostate tissue with a grooved roller-bar that vaporizes tissue. The immediate tissue loss leads to quick improvement of symptoms. The procedure takes from 20 to 65 minutes. The catheter is usually removed within 24 hours and most patients go home within 2 days.

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