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48 7° Congresso Nazionale Associazione Italiana di Endourologia present time there is not enough critical data to support the hypothesis that TUMT challenges TURP, further studies that provide high quality of evidence are needed. Hoffman et al (11) combined all evidence from randomized controlled trials evaluating the efficacy and safety of microwave thermotherapy in treating men with LUTS and BPH, in order to quantify the therapeutic efficacy. Overall, 540 patients were randomized in the six eligible randomized studies, including 322 to TUMT and 218 to TURP. Patients included in the studies had moderate to severe LUTS, with decreased Qmax and moderately enlarged prostates. Studies generally excluded men with very large prostates (>100 g), prominent median lobes and in urinary retention. Treatment was offered by different TUMT devices and software including Prostatron (Prostatsoft 2.0 and 2.5) and ProstaLund Feedback. The mean (range) age was 67.8 (65- 70) years, baseline symptom score 19.5 (15.7-21.3), baseline Qmax 8.6 (7.9-10.1) ml/sec and prostate volume 44.5 (33.9-52.7) ml, and did not differ by treatment group. Two studies followed patients for 6 months and 4 studies provided a 12-month follow-up. Five studies found significant decreases in urinary symptoms and significant increases in Qmax between baseline and follow-up for both TURP and TUMT. Three studies (12-14) evaluated the effect of treatment on QOL using the eight IPSS question. The pooled mean QOL score for men undergoing TUMT decreased by 58.5% (4.1 to 1.7) and by 63.4% (4.1 to 1.2) in men undergoing TURP. Although QOL significantly improved after both TUMT and TURP, there were no significant differences between treatments. Muttiasson et al (15,16) have published the results of a prospective randomised study, including 154 patients randomized to TUMT or TURP. Total IPSS decreased 3 months after surgery from 21 to 8 (61.9%) in the TUMT group and from 20 to 7(65%) in the TURP group, which was sustained over 5 years. Max flow rate and IPSS QoL were comparable between the two groups. In the TUMT group were observed few severe complications (5%) and 10 % of patients needed additional treatment. The burning question for thermal-based treatment is how good the results remain in a long-term perspective. Historically the Low-Energy TUMT has been abandoned due to the disappointing durability of its effects. Recent studies confirm the limited durability of clinical outcome obtained by lower energy programs, with a retreatment rate as high as 84.4% after 5-year follow-up (17-19). In the randomized study with the longest available follow-up by Floratos et al (12), the results of 36 month follow-up were presented. Improvement in Qmax of the TUMT group from 9.2 ml/sec retreatment to 15.1 ml/sec, 14.5 ml/sec and 11.9 ml/sec at 1-, 2 and 3 years, respectively, was reported, whilst the IPSS symptom score improved from 20 to 8, 9 and 12, respectively. These data indicate that the level of improvement is durable up to 3 years. The retreatment rate for TUMT and TURP was 19.8% and 12.9%, respectively. It is important to underline the different causes of retreatment. Retreatment was offered to the TUMT patients because of primary treatment failure, while in the TURP group, retreatment included reintervention mainly because of urethral strictures, bladder neck sclerosis, meatal stenosis, but rarely, treatment failure. Similarly, Trock et al (20) performed a pooled analysis of 6 multicenter studies of cooled thermotherapy with compa- Archivio Italiano di Urologia e Andrologia 2007, 79, 3, Supplemento 1 rable baseline measures. In total 541 patients were pooled and data showed an improvement of 55%, 53% and 51% in AUA symptom score, QOL and Qmax after TUMT, respectively. A slight decrease was observed at 48 months since subjective and objective improvement remained durable (43%, 50% and 35%, respectively). One of the commonly used arguments for the application of TUMT as an alternative to TURP for BPH is its low morbidity. The reported low morbidity and the absence of any need for spinal or general anesthesia make TUMT a true outpatient procedure, representing an excellent option for patients at high operative risk (American Society of Anesthiologists class 3 or 4) who are unsuitable for an invasive treatment. TRANS-URETHRAL NEEDLE ABLATION (TUNA) TUNA therapy uses low-level radiofrequency (RF) energy that is delivered by needles into the prostate and that produces localized necrotic lesions in the hyperplasic tissue. The inner region of the prostate is selectively ablated with temperatures approaching 90-100°C while the prostatic urothelium is preserved (21,22). The TUNA system consists of a special catheter attached to a generator. At the end of the catheter there are two needles that are withdrawn into two adjustable shields made from Teflon. The needles are advanced into the prostatic tissue and can be placed accurately into the required position. The generator produces a monopolar RF signal of 490 kHz, which allows excellent heat penetration and uniform tissue distribution of heat (21,22). The advantage of TUNA is that it can be delivered under topical anesthesia to patients with symptomatic BPH and is an attempt to minimize operative risk and reduce postoperative sequela and the need for a long recovery period, while optimizing the therapeutic benefit. There is a wide variety in the number of patients in each series and in the length of follow-up. It can be noted that most are open series, with a minority of randomized studies. The size of studies varies from 10 to 188 patients, and, in many cases, the number of patients, followed up for a long period of time is less than 50% of the original sample, which makes it difficult to draw definitive conclusions (22). The results of 5 year follow-up of the United States randomized clinical trial were presented (23). Following treatment, significant improvement from baseline occurred in symptom score, higher for TURP than for TUNA (statistically significant in the first 4 years). The two groups demonstrated a significant improvement in maximum urinary flow rate (greater for TURP patients). TUNA showed significantly fewer adverse events than TURP. The TURP group reported 41% retrograde ejaculation, while the TUNA group reported none. However, in the TUNA group 14% required further intervention with additional treatment (TURP), against only 2% in the TURP cohort. The results of this study demonstrate stable treatment outcomes after 5 years of follow up and suggest that TUNA is an attractive treatment option for men with LUTS due to BPH. While the TURP improvement was superior, TUNA showed lower adverse events (23). Another randomized clinical trial comparing TUNA with TURP analyzed 59 patients (24). Improvements in Qmax, post voiding residual volume (PVR), IPSS and the QOL score were statistically significant for both groups at 3 and 18 months of fol-
low-up. The increase in the mean Qmax of the TURP group was higher than that in the TUNA group, whereas no significant differences were found between the two groups regarding improvements in IPSS and QOL scores. There were no complications associated with the TUNA procedure, while after TURP 16 patients suffered from retrograde ejaculation, 4 from erectile impairment, 2 from urethral stenosis and 1 from urinary incontinence (24). A recent meta-analysis (25) analyzed the data from two randomized trials (23,26), two non-randomized protocols (27,28) and 10 single-arm studies conducted on TUNA (27,29,30,31,32,33,34,35,36). The effect of TUNA was a decrease of the mean IPSS by 50% from baseline at 1 year after treatment. This effect maintained up to 5 years. The Qmax increased by 70% from baseline after 1 year in virtually all studies and approached or exceeded 15 ml/sec. Although there was a tendency for the Qmax to decline slightly over time, the mean Qmax 5 years after treatment was more than 50% improved compared to baseline. When only the two randomized trials are considered, the mean decline in IPSS was 11.6 after TUNA and 15.7 after TURP (difference statistically significant). The effect of TUNA therapy on Qmax (+7.0 ml/sec) was smaller than that of TURP (+11.6 ml/sec= statistically significant) (25). This meta-analysis shows that TUNA is an effective and minimally invasive treatment for men, even with severe symptoms. There is a significant improvement in symptoms and flow rate after 1 year which persists for at least 5 years. TUNA therapy would appear to be an alternative to surgery and an attractive option for men who do not wish to undergo long-term medical therapy, for men who are poor candidates for surgery or those concerned about the side-effects of TURP (25). Although a 14% requirement for re-operation due to the lack of efficacy of the primary treatment with TUNA may seem low, it occurred within 2 years (23). In addition, the 12.7% incidence reported by other authors also occurred within a 2 year period (27). INTERSTITIAL LASER COAGULATION OF THE PROSTATE (ILC) In 1991 Hofstetter introduced ILC of the prostate (37). In this technique, Nd: YAG, a diode or holmium laser fibers are placed directly into the prostatic adenoma. The fiber is fitted with a special diffuser tip or used as a bare fiber placed percutaneously through the perineum or directly through a cystoscope. The Nd: YAG laser fiber is left in position for 10 minutes at 5 to 10 W. The diode laser requires a 3-minute treatment at each location starting at 20 W and decreasing to 7 W in the “turbo mode”. The aim of this technique is to preserve the urethra, thus preventing tissue sloughing with less storage symptoms than seen with other laser techniques. Martenson and de la Rosette (38,39) reported a comparative study between ILC and TURP in 30 and 14 patients, respectively with 2 years follow up. The retreatment rate for the ILC group was 21% compared to 7% in the TURP group, no incontinence was documented in either group, with one patient in the TURP group developing a urethral stricture. The storage symptoms are frequent and long post-operative catheterization is required for up to one month in some studies. To achieve immediate relief of obstruction, some authors perform a 7° Congresso Nazionale Associazione Italiana di Endourologia limited resection of the coagulated tissues immediately after ILC (40). A multicenter randomized trial at six U.S hospitals comparing TURP (n=35) with ILC (n=37) was published by Kursh et al. (41). At 2-years follow up, the Qmax improved by 81% in the TURP group (from 9.1 to 16.5 ml/sec) and by 51% in the ILC group (from 9.2 to 13.9 ml/sec). The improvement in AUA symptom index was 70% in the TURP group and 63% in the ILC group. The ILC group had a significantly shorter hospital stay and a better sexual function score. The urinary tract infection rate in ILC group was 20%, the retreatment rate was 16% and no decrease in PSA was noted at 2 years (42). Floratos et al (43) reported on long-term follow up (34 to 53 months) after VLAP (n=107), contact laser (n=30), and ILC (n=53). The retreatment rate was higher in ILC group than other groups (41% vs 14%). Similar retreatment rate (35%) within 8 years after ILC was reported by Terada et al. (44). The EUA guidelines suggest using the ILC only in the treatment of high-risk patients (45). PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE (PVP) The potassium Titanyl phosphate:YAG (KTP) laser is based on the technique of passing Nd: YAG laser light through a KTP crystal. This halves the wavelength of the emitted laser to 532 nm and doubles its frequency. The emitted light is a visible green light, which is strongly absorbed by red tissues and hemoglobin; this means that a blood rich organ such as the prostate gland is an excellent target. Based on these qualities, its name (photoselective vaporization of the prostate) was coined (46). Recently an 80 W KTP laser generator was developed. Hai and Te et al (47) reported the first multicenter study of 139 patients with a mean prostate volume of 54.6 cc who underwent 80 WKTP laser vaporization of the prostate with a 12- month follow-up. The mean operative time was 38.7 minutes, the mean catheterization time was 14 hours and 32% of patients required no post-operative catheterization, thus making PVP a costeffective procedure. There was an 82% improvement in symptom score, 190% improvement in Qmax, and 37% reduction in prostate volume. The postoperative complications included dysuria (9.4%), transient hematuria (8.6%), transient urge incontinence (6.5%) recatheterization (5%), retrograde ejaculation (36%) bladder neck contracture (1.4%) and urethral stricture (0.7%). Long-term results demonstrated sustained improvement in voiding parameters. Of 84 patients who underwent PVP, Malek and Kuntsman (48) reported 80% improvement in symptom score and 170% to 250% improvement in the Qmax after 5 years follow- up, with no need for re-operation. HOLMIUM LASER RESECTION OF THE PROSTATE (HOLRP) This procedure is similar to the standard TURP. Resection of the prostate is achieved by using the end firing Ho: YAG laser fiber. The procedure is started with bilateral incisions to define the depth and amount of tissue to be removed. In 1996 Gilling et al (49) reported the results of the initial 84 patients who underwent HoLRP. The mean AUA symptom score improved from 21.3 pre-operatively to 4.1 at 3 months. The mean Qmax increased from 7.5 to 19.3 Archivio Italiano di Urologia e Andrologia 2007, 79, 3, Supplemento 1 49
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Periodico trimestrale - Spedizione
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7° Congresso Nazionale Associazion
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16 Settembre 2007 7° Congresso Naz
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Ore 17:30-18:30 Golden video Tratta
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Aula Rossa Video Laparoscopia 1 Mod
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Quale TURP: mono o bipolare? C. Ter
Page 15 and 16: 19 settembre 2007 Ore 8:00-9:00 Aul
Page 17 and 18: Ore 9:00-13:30 AUDITORIUM 7° Congr
Page 19 and 20: ABSTRACTS Golden Communications 18
Page 21 and 22: in due casi è stata effettuata una
Page 23 and 24: Materiali e Metodi: con un doppio c
Page 25 and 26: in tutte le altre forme di neoplasi
Page 27 and 28: trissia; in 5 casi sono state utili
Page 29 and 30: manovre endourologiche per la rimoz
Page 31 and 32: matica. Non sono state registrate c
Page 33 and 34: Materiali e Metodi: Presentiamo il
Page 35 and 36: elativamente semplice, riproducibil
Page 37 and 38: Conclusioni: L’incisione laser pe
Page 39 and 40: ma è poco indicata per le fistole
Page 41 and 42: metriosi vescicale. Successivamente
Page 43 and 44: emostasi GYRUS è stata introdotta
Page 45 and 46: mento di scelta per la sua mininvas
Page 47 and 48: stent in quanto in 1 sono stati pos
Page 49 and 50: ilaterale in 3 casi, diretta e bila
Page 51 and 52: vaso di urina è stato trattato con
Page 53 and 54: endovision è piu’ sicura nell’
Page 55 and 56: Il terzo tempo è costituito dal po
Page 57 and 58: mente ricavato tra retto e vagina.
Page 59 and 60: The role of fluorescent cystoscopy
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Page 63 and 64: RESULTS All patients are alive; for
Page 65: 7° Congresso Nazionale Associazion
Page 69 and 70: REFERENCES 1. Reich O, Gratzke C, S
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