Benign Prostatic Hyperplasia

1. Benign Prostatic Hyperplasia

3. Secretes semen which carries sperm During orgasm, prostate muscles contract and propel ejaculate out of the penis

4. The size of prostate enlarged microscopically since the age of 40.Half of all men over the age of 60 will develop an enlarged prostate By the time men reach their 70’s and 80’s, 80% will experience urinary symptoms But only 25% of men aged 80 will be receiving BPH treatment

7. What causes BPH? BPH is part of the natural aging process, like getting gray hair or wearing glasses BPH cannot be prevented BPH can be treated

8. What’s LUTS? Voiding (obstructive) symptoms Hesitancy Weak stream Straining to pass urine Prolonged micturition Feeling of incompletebladder emptying Urinary retention Storage (irritative or filling) symptoms Urgency Frequency Nocturia Urge incontinence LUTS can arise from a variety of causes, for example as a consequence of prolonged urinary obstruction due to BPH. LUTS are categorised as being obstructive (voiding) or irritative (storage) symptoms. Obstructive symptoms include hesitancy, weak stream, straining to pass urine, prolonged micturition, feeling of incomplete bladder emptying, and urinary retention. Irritative symptoms include urgency, frequency, nocturia, and urge incontinence. LUTS may also be due to inflammatory or infectious processes.LUTS can arise from a variety of causes, for example as a consequence of prolonged urinary obstruction due to BPH. LUTS are categorised as being obstructive (voiding) or irritative (storage) symptoms. Obstructive symptoms include hesitancy, weak stream, straining to pass urine, prolonged micturition, feeling of incomplete bladder emptying, and urinary retention. Irritative symptoms include urgency, frequency, nocturia, and urge incontinence. LUTS may also be due to inflammatory or infectious processes.

9. Diagnosis of BPH The initial evaluation can be done either by a Primary Care Practitioner (PCP) or by a urologist. If the initial evaluation suggests a diagnosis of BPH, the physician can proceed to develop an appropriate treatment plan. The physical examination should include specific attention to the presence or absence of a distended bladder, urethral discharge, genital abnormalities, and neurologic abnormalities that can affect voiding. A digital rectal examination (DRE) is considered an important part of the physical examination of any patient complaining of symptoms of prostatism. This examination is conducted with a well-lubricated, gloved index finger, which is used to palpate the prostate gland and the surrounding tissues through the wall of the rectum. Because of the prevalence of prostatic disease in older men, many physicians conduct DREs as part of the routine annual physical examination of any man over the age of 50 years. The size, consistency, shape, and symmetry of the prostate gland can be felt through the rectal wall during a DRE. Several questionnaires are used to assess the severity of symptoms and their impact on a patient’s QoL. American Urology Association-Symptom Score (AUA-SI) or International Prostate Symptom Score (IPSS), QoL score and BPH-II. In men with symptoms of BPH, a urine sample should be examined for signs of a urinary tract infection or haematuria, both of which suggest a non-BPH cause for the LUTS. Both urinary tract infections and bladder cancer can produce symptoms similar to those produced by BPH. The initial evaluation can be done either by a Primary Care Practitioner (PCP) or by a urologist. If the initial evaluation suggests a diagnosis of BPH, the physician can proceed to develop an appropriate treatment plan. The physical examination should include specific attention to the presence or absence of a distended bladder, urethral discharge, genital abnormalities, and neurologic abnormalities that can affect voiding. A digital rectal examination (DRE) is considered an important part of the physical examination of any patient complaining of symptoms of prostatism. This examination is conducted with a well-lubricated, gloved index finger, which is used to palpate the prostate gland and the surrounding tissues through the wall of the rectum. Because of the prevalence of prostatic disease in older men, many physicians conduct DREs as part of the routine annual physical examination of any man over the age of 50 years. The size, consistency, shape, and symmetry of the prostate gland can be felt through the rectal wall during a DRE. Several questionnaires are used to assess the severity of symptoms and their impact on a patient’s QoL. American Urology Association-Symptom Score (AUA-SI) or International Prostate Symptom Score (IPSS), QoL score and BPH-II. In men with symptoms of BPH, a urine sample should be examined for signs of a urinary tract infection or haematuria, both of which suggest a non-BPH cause for the LUTS. Both urinary tract infections and bladder cancer can produce symptoms similar to those produced by BPH.

11. Interfere with sexual life

12. When should BPH be treated? BPH needs to be treated ONLY IF: Symptoms are severe enough to bother the patient and affect his quality of life Complications related to BPH

13. Choosing the right treatment Consider risks, benefits and effectiveness of each treatment Consider the outcome and lifestyle needs

14. “Watchful waiting” Medication Surgical approaches Minimal invasive TURP Invasive “open” procedures

15. “watchful waiting” For mild symptoms. follow up1 to 2 times yearly

16. Medication First line of defense against bothersome urinary symptoms Two major types: a blockers - relax the smooth muscle of prostate and provide a larger urethral opening (Hytrin,Doxaben, Harnalidge) Relaxation of these muscle bundles lessens the resistance to outflow during urination.aRelaxation of these muscle bundles lessens the resistance to outflow during urination.a

17. Benefits Convenient No loss of work time Minimal risk Disadvantages Drug Interactions Must be taken every day Manages the problem instead of fixing it Medications address the desire we all have to find a “cure” to fix the problem. We all like a “quick and easy” solution. They can, however, become less effective over time. Studies have shown that people tend to become less careful about following directions regarding the dose and/or frequency of taking their medication. Medications address the desire we all have to find a “cure” to fix the problem. We all like a “quick and easy” solution. They can, however, become less effective over time. Studies have shown that people tend to become less careful about following directions regarding the dose and/or frequency of taking their medication.

18. Possible side effects of  Impotence Dizziness Headaches Fatigue Loss of sexual drive Relaxation of these muscle bundles lessens the resistance to outflow during urination.Relaxation of these muscle bundles lessens the resistance to outflow during urination.

19. ?-Adrenergic Blockers: Rationale Prostate smooth muscle tone is mediated via ?1-adrenergic receptor Blockage of the receptor leads to improvement of flow rate and LUTS1 Central ?-receptors and the effect of agents on these receptors likely play an additional role Density of adrenergic receptors changes with prostate size and age Three ?1-adrenergic receptor subtypes have been identified (A, B, D) [Dr. McVary, transcript page 26] Prostate smooth muscle tone is mediated via ?1-adrenergic receptors. Increased tone of the prostate smooth muscle leads to BOO and a reduction in urinary flow rate. Blockage of the ?1-adrenergic receptor relaxes prostate smooth muscle and relieves BOO.1 Studies indicate that, overall, ?1-adrenergic receptor expression doubles with age (<55 y vs ?65 y).2 To date, three ?1-adrenergic receptor subtypes have been identified: ?1A, ?1B, and ?1D.1 Schwinn DA. Novel role for ?1-adrenergic receptor subtypes in lower urinary tract symptoms. BJU Int. 2000;86(suppl 2):11-22. Rudner XL, Berkowitz DE, Booth JV, et al. Subtype specific regulation of human vascular ?1-adrenergic receptors by vessel bed and age. Circulation. 1999;100:2336-2343. [Dr. McVary, transcript page 26] Prostate smooth muscle tone is mediated via ?1-adrenergic receptors. Increased tone of the prostate smooth muscle leads to BOO and a reduction in urinary flow rate. Blockage of the ?1-adrenergic receptor relaxes prostate smooth muscle and relieves BOO.1 Studies indicate that, overall, ?1-adrenergic receptor expression doubles with age (<55 y vs ?65 y).2 To date, three ?1-adrenergic receptor subtypes have been identified: ?1A, ?1B, and ?1D.1 Schwinn DA. Novel role for ?1-adrenergic receptor subtypes in lower urinary tract symptoms. BJU Int. 2000;86(suppl 2):11-22. Rudner XL, Berkowitz DE, Booth JV, et al. Subtype specific regulation of human vascular ?1-adrenergic receptors by vessel bed and age. Circulation. 1999;100:2336-2343.

20. Distribution of ?1-Adrenergic Receptors

21. Localization of ?1-Adrenergic Receptors (?1-ARs)

22. ?-Blockers Nonselective Phenoxybenzamine Short-acting selective a1-blocker Prazosin, Alfuzosin Long-acting selective a1-blockers Terazosin Doxazosin Long-acting selective a1A-subtype Tamsulosin Alfuzosin-SR

23. ?1-Adrenergic Blockers: Summary All currently available ?1-blockers induce fast improvement in LUTS and flow rate parameters with similar efficacy They are all well tolerated; however, the adverse event spectrum differs between the agents Terazosin and doxazosin induce more dizziness, fatigue, and asthenia Tamsulosin induces more ejaculatory disturbances None of the ?1-blockers alter urodynamic parameters, prostate volume or serum PSA None have been shown to alter the natural history of the disease or prevent AUR / Surgery Alpha-1 Blockers: Conclusions In conclusion, all alpha blockers currently available induce fast improvement in LUTS and flow rate parameters, with similar efficacy across all alpha blockers These agents are all well tolerated; however, the adverse event spectrum differs between the agents with Terazosin and doxazosin inducing more dizziness, fatigue and asthenia Tamsulosin inducing more ejaculatory disturbances Nevertheless, none of the alpha blockers alter prostate volume or serum PSA, and none have been shown to significantly change the rate of AUR/surgeryAlpha-1 Blockers: Conclusions In conclusion, all alpha blockers currently available induce fast improvement in LUTS and flow rate parameters, with similar efficacy across all alpha blockers These agents are all well tolerated; however, the adverse event spectrum differs between the agents with Terazosin and doxazosin inducing more dizziness, fatigue and asthenia Tamsulosin inducing more ejaculatory disturbances Nevertheless, none of the alpha blockers alter prostate volume or serum PSA, and none have been shown to significantly change the rate of AUR/surgery

24. 5?-Reductase Inhibitor: Rationale Prostatic differentiation & growth depend on androgenic stimulation Testosterone is converted to dihydrotestosterone (DHT) within the prostatic stromal & basal cells facilitated by 5?-reductase enzyme 5?-reductase inhibitor: deprive the prostate of its testosterone support 5?-reductase enzyme: Type I: skin & liver Type II: stromal & basal cells of prostate, seminal vesicle, epididymis

25. Regulation of cell growth in the prostate in BPH

26. 5a-reductase inhibition Mode of action

27. Greater and more consistent suppression of DHT observed with dutasteride versus finasteride (n=399)

28. Comparison of adverse events: Dutasteride vs. finasteride vs. placebo(n=399)

29. Dutasteride 4-year studies (2-year double-blind and 2-year open-label)

30. Dutasteride therapy results in reductions in total prostate volume from 1–24 months that are sustained to 4 years

31. Dutasteride therapy results in symptom improvements from 6 months, with continuing improvements over 4 years (completers)

32. Dutasteride therapy results in improvements in urinary flow from 1 month, with continuing improvements over 4 years

33. Acute urinary retentionKaplan-Meier estimates: time to first event Dutasteride was associated with a significant reduction in the risk of AUR (57%) compared to placebo during the first 2 years of the studies Between 2-4 years, when all patients are receiving dutasteride, AUR occurred at a lower rate in the switchers than observed for these patients in years 0-2, and at a rate consistent with that seen in dutasteride-treated patients between 0-2 years.Dutasteride was associated with a significant reduction in the risk of AUR (57%) compared to placebo during the first 2 years of the studies Between 2-4 years, when all patients are receiving dutasteride, AUR occurred at a lower rate in the switchers than observed for these patients in years 0-2, and at a rate consistent with that seen in dutasteride-treated patients between 0-2 years.

34. BPH-related surgeryKaplan-Meier estimates: time to first event Dutasteride was associated with a significant reduction in the risk of BPH-related surgery (48%) compared to placebo during the first 2 years of the studies Between 2-4 years, when all patients are receiving dutasteride BPH-related surgery occurred in a small percentage of men, at slightly lower rates than seen in dutasteride-treated men between 0-2 years Dutasteride was associated with a significant reduction in the risk of BPH-related surgery (48%) compared to placebo during the first 2 years of the studies Between 2-4 years, when all patients are receiving dutasteride BPH-related surgery occurred in a small percentage of men, at slightly lower rates than seen in dutasteride-treated men between 0-2 years

35. PSA is reduced in a predictable manner preserving its prostate cancer screening utility

36. Long-term change in prostate volumeIndirect comparison of dutasteride, finasteride and a-blockers

37. Symptom improvementIndirect comparison of a-blockers, finasteride and dutasteride  As this is not comparator data patient populations from the various studies may differ. dutasteride data for 1, 2 and 4 years is shown in yellow. Continuing improvement in symptoms over the 4 years is seen. Finasteride data for 1, 4 and 5 years is shown red, including that from PLESS & MTOPS. Alpha blocker data for 13 weeks to 5 years in shown in green. dutasteride symptom improvement at 4 years is comparable to that seen for alpha blockers. As this is not comparator data patient populations from the various studies may differ. dutasteride data for 1, 2 and 4 years is shown in yellow. Continuing improvement in symptoms over the 4 years is seen. Finasteride data for 1, 4 and 5 years is shown red, including that from PLESS & MTOPS. Alpha blocker data for 13 weeks to 5 years in shown in green. dutasteride symptom improvement at 4 years is comparable to that seen for alpha blockers.

38. 5ARIs?a-blockers ?????? Different classes of treatment for BPH have different effects on the natural history of the disease Alpha blockers treat symptoms and delay, but do not reduce the risk of, AUR and surgeryDifferent classes of treatment for BPH have different effects on the natural history of the disease Alpha blockers treat symptoms and delay, but do not reduce the risk of, AUR and surgery

39. Combination therapy with 5aRIs and a1 blockers

40. Rationale for Combination Therapy Alpha blockers relax the smooth muscle of bladder neck and prostatic capsule/adenoma, thereby improving symptoms and flow rates, relieving obstruction 5 ARIs reduce the action of androgens in the prostate, inducing apoptosis, atrophy, and, by shrinking the prostate improve symptoms, relieve obstruction and prevent AUR & prostate surgery

42. Change in AUA Symptom Score at Year 4 Median baseline AUA SS = 17.0

43. Change in Qmax at Year 4 Median baseline Qmax = 10.6

44. Conclusions Single arm therapy with alpha blocker Improve symptoms and prevent symptom progression Does not alter natural history or cross over to invasive therapy Single arm therapy with 5 ARI Treats symptoms only when LUTS associated with BPH (ie enlargement or high PSA) Alters natural history in pts at risk (large gland, high PSA) Combination (doxazosin+finasteride) therapy is the most effective form of treatment for LUTS and BPH Improve symptoms and flow rate Prevent AUR and/or surgery Alter the natural history of the disease

45. SMART–1 was designed to examine short-term dutasteride and a1-blocker combination therapy, followed by dutasteride monotherapy Entry criteria: IPSS ? 12 PV ? 30 cc, estimated by DRE PSA 1.5 – 10.0 ng/ml Symptom Management After Reducing Therapy: SMART–1

46. SMART-1: study design SMART-1 was a randomised, blinded, parallel group, multi-centre pilot study in male subjects with symptomatic BPH. Eligible subjects were entered into a four week single-blind placebo run-in phase prior to randomisation to Avodart 0.5mg plus tamsulosin 0.4mg combination therapy for 24 weeks. At the 24-week time-point, approximately half of the subjects had tamsulosin removed from their treatment regimen in a double-blinded manner. These subjects received Avodart monotherapy for a further 12 weeks (to week 36). The other group of subjects continued to receive Avodart plus tamsulosin combination therapy for a further 12 weeks (to week 36). SMART-1 was a randomised, blinded, parallel group, multi-centre pilot study in male subjects with symptomatic BPH. Eligible subjects were entered into a four week single-blind placebo run-in phase prior to randomisation to Avodart 0.5mg plus tamsulosin 0.4mg combination therapy for 24 weeks. At the 24-week time-point, approximately half of the subjects had tamsulosin removed from their treatment regimen in a double-blinded manner. These subjects received Avodart monotherapy for a further 12 weeks (to week 36). The other group of subjects continued to receive Avodart plus tamsulosin combination therapy for a further 12 weeks (to week 36).

47. SMART-1: primary endpoint questionat week 30 by baseline IPSS Approx 1/10 patients responded that they were worse at week 30, after withdrawal of the alpha blocker at week 24. As could be expected those patients who responded that they were worse following withdrawal of the alpha blocker were likely to have a severe IPSS score at baseline. Approx 1/10 patients responded that they were worse at week 30, after withdrawal of the alpha blocker at week 24. As could be expected those patients who responded that they were worse following withdrawal of the alpha blocker were likely to have a severe IPSS score at baseline.

48. 5 a Reductase Inhibitors????

49. Conclusions In MTOPS study, finasteride afforded long-term reduction in risk of AUR on surgery when combined with alpha 1-blocker doxazosin 5ARI ?alpha blocker??????,???BPH???????,???????????????BPH???????? In SMART-1 study, dutasteride can be used in combination with tamsulosin to achieve fast symptom relief that is maintained with alpha 1- blocker is removed after 6 months ???????????BPH???????,Avodart ??alpha blocker????,????????6?????alpha blocker

50. Medical Therapy Algorithm No change requested. No change requested.

51. Surgical treatment Until recently, the only option we could offer patients for treatment of their symptoms was either an open abdominal surgical procedure, or a trans-urethral resection of the prostate.Until recently, the only option we could offer patients for treatment of their symptoms was either an open abdominal surgical procedure, or a trans-urethral resection of the prostate.

52. Treatment Modalities for BPH Watchful waiting Medical therapy Phytotherapy ?-adrenergic blockers 5?-reductase inhibitors Combination therapy Office-based treatment TUMT TUNA WIT Surgicenter/Hospital-based treatment TURP (gold standard) TUIP Open surgery (prostatectomy) TUVP ILC VLAP Prostatic stents [Dr. McVary, transcript page 24] Treatment options for BPH include watchful waiting, medical therapy, and various surgical procedures.1-3 About 42% of patients treated with placebo or watchful waiting report symptomatic improvement compared with about 98% for open prostatectomy.2 Symptom improvement with medical treatment is less than that with surgical procedures. The mean probability of symptomatic improvement is 74% with an ?-adrenergic blocker versus 98% with an open prostatectomy.2 However, disadvantages of surgery include invasiveness, a period of recuperation and, in the case of open surgery, a comparatively prolonged hospitalization.3 Watchful waiting is a strategy of management/monitoring in which patients receive no active treatment.2 Phytotherapy involves the use of plant extracts for medicinal uses.4 Today, ?-adrenergic blockers, which inhibit contraction of prostatic smooth muscle, are first-line treatment for LUTS/BPH. Another pharmacologic option is the 5ARI, finasteride, which lowers prostatic androgen levels and can result in some decrease in prostate size. Office-based procedures include transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA). Transurethral resection of the prostate (TURP), the gold standard and most common active treatment, is the surgical removal of the prostate’s inner portion, using an endoscopic approach through the urethra.2,3 Transurethral incision of the prostate (TUIP) is also an endoscopic surgical procedure. Patients with smaller prostates (<30 g) have an instrument inserted through the urethra to make one or two cuts in the prostate that reduce urethral constriction.2,3 Open surgery (prostatectomy) is the surgical removal of the prostate via an incision in the lower abdomen.2,3 Transurethral vaporization of the prostate (TUVP or TVP) applies electrical energy to electrosurgically vaporize the obstructive enlarged prostatic tissue. The laser is inserted under direct vision into the prostate and activated to destroy the surrounding tissue.3 With visual laser ablation of the prostate (VLAP), a laser fiber is passed into the prostatic channel under telescopic guidance to destroy the obstructing portions of the prostate. Stents are wire devices shaped like small springs or coils, which are placed within the prostate channel to keep the channel open.3 Chatelain C, Denis L, Foo JKT, et al. 5th International Consultation on BPH. Recommendations of the International Scientific Committee: Evaluation and treatment of lower urinary tract symptoms (LUTS) in older men. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001:519-534. McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline, Number 8. AHCPR Publication No. 94-0582. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. February 1994. Columbia University website. Therapies for the treatment of benign prostatic hyperplasia (BPH). Available at http://cpmcnet.columbia.edu/dept/urology/bphtherapy.html#translas. Accessed 8/23/01. Dreikorn K, Lowe I, Borkowski A, et al. Other medical therapies. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;479-511.[Dr. McVary, transcript page 24] Treatment options for BPH include watchful waiting, medical therapy, and various surgical procedures.1-3 About 42% of patients treated with placebo or watchful waiting report symptomatic improvement compared with about 98% for open prostatectomy.2 Symptom improvement with medical treatment is less than that with surgical procedures. The mean probability of symptomatic improvement is 74% with an ?-adrenergic blocker versus 98% with an open prostatectomy.2 However, disadvantages of surgery include invasiveness, a period of recuperation and, in the case of open surgery, a comparatively prolonged hospitalization.3 Watchful waiting is a strategy of management/monitoring in which patients receive no active treatment.2 Phytotherapy involves the use of plant extracts for medicinal uses.4 Today, ?-adrenergic blockers, which inhibit contraction of prostatic smooth muscle, are first-line treatment for LUTS/BPH. Another pharmacologic option is the 5ARI, finasteride, which lowers prostatic androgen levels and can result in some decrease in prostate size. Office-based procedures include transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA). Transurethral resection of the prostate (TURP), the gold standard and most common active treatment, is the surgical removal of the prostate’s inner portion, using an endoscopic approach through the urethra.2,3 Transurethral incision of the prostate (TUIP) is also an endoscopic surgical procedure. Patients with smaller prostates (<30 g) have an instrument inserted through the urethra to make one or two cuts in the prostate that reduce urethral constriction.2,3 Open surgery (prostatectomy) is the surgical removal of the prostate via an incision in the lower abdomen.2,3 Transurethral vaporization of the prostate (TUVP or TVP) applies electrical energy to electrosurgically vaporize the obstructive enlarged prostatic tissue. The laser is inserted under direct vision into the prostate and activated to destroy the surrounding tissue.3 With visual laser ablation of the prostate (VLAP), a laser fiber is passed into the prostatic channel under telescopic guidance to destroy the obstructing portions of the prostate. Stents are wire devices shaped like small springs or coils, which are placed within the prostate channel to keep the channel open.3 Chatelain C, Denis L, Foo JKT, et al. 5th International Consultation on BPH. Recommendations of the International Scientific Committee: Evaluation and treatment of lower urinary tract symptoms (LUTS) in older men. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001:519-534. McConnell JD, Barry MJ, Bruskewitz RC, et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline, Number 8. AHCPR Publication No. 94-0582. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. February 1994. Columbia University website. Therapies for the treatment of benign prostatic hyperplasia (BPH). Available at http://cpmcnet.columbia.edu/dept/urology/bphtherapy.html#translas. Accessed 8/23/01. Dreikorn K, Lowe I, Borkowski A, et al. Other medical therapies. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;479-511.

53. Indication of surgical intervention Acute urinary retention Gross hematuria Frequent UTI Vesical stone BPH related hydronephrosis or renal function deterioration Obstruction IPSS?8, prostate size, image study, UFR cystoscopic findings, residual urine

54. Conventional Surgical Therapy Transurethral resection of the prostate (TURP) Open simple prostatectomy

56. TURP “Gold standard” of surgical treatment for BPH 80~90% obstructive symptom improved 30% irritative symptom improved Low mortality rate 0.2%

57. The “gold standard”- TURP Benefits Widely available Effective Long lasting Disadvantages Greater risk of side effects and complications 1-4 days hospital stay 1-3 days catheter 4-6 week recovery

58. Complication of TURP Immediate complication bleeding capsular perforation with fluid extravasation TUR syndrome Late complication urethral stricture bladder neck contracture (BNC) retrograde ejaculation impotence (5-10%) incontinence (0.1%)

59. Open Simple Prostatectomy “too large prostate” -- >100 gm Combined with bladder diverticulum or vesical stone surgery Suprapubic or retropubic method

60. Minimally invasive therapy During the last decade, numerous amounts of minimally invasive therapy modalities have been developed to challenge the traditional surgery of TURP The aim of these therapies is to achieve results similar to TURP but with minimal anesthesia, complication, risk and hospital stay.

61. Minimally invasive therapy for BPH transurethral balloon dilatation of the prostate (TUBDP) transurethral incision of the prostate (TUI) intraprostatic stent transurethral microwave thermotherapy (TUMT) transurethral needle ablation of the prostate (TUNA) transurethral electrovaporization of the prostate (TUVP) photoselective vaporization of the prostate (PVP), Cryotherapy Transurethral ethanol ablation of the prostate (TEAP),

62. Minimally invasive therapy for BPH transurethral laser-induced prostatectomy (TULIP) visual laser ablation of the prostate (VLAP) contact laser prostatectomy (CLP) interstitial laser coagulation of the prostate (ILC) holmium:YAG laser resection of the prostate (HoLRP) holmium:YAG laser enucleation of the prostate (HoLEP) high-intensity focused ultrasound (HIFU) coagulation botulinum toxin-A injection of the prostate

63. HoLEP Vs. TURP IPSS & urodynamic findings: no statistically significant differences Operation time: HoLEP 74 +/- 19.5 vs. TURP 57 +/- 15 mins (p <0.05) Catheterization time: 31 +/- 13 vs 57.78 +/- 17.5 hours (p <0.001) Hospital stay: 59 +/- 19.9 vs 85.8 +/- 18.9 hours (p <0.001) Urge incontinence: more common in the HoLEP group The overall complication rate was comparable in the 2 groups

64. TURP vs HIGH POWER (80 W) POTASSIUM TITANYL PHOSPHATE (KTP) LASER VAPORIZATION Hemostasis: standardized ablation volume of 16 cm3 tissue (23.3 vs 2.1 ml per minute, p <0.0001). Tissue ablation: more rapid in the resection group (100 vs 20 seconds, p <0.001). Histological examinations: larger coagulation zones for the KTP group compared to conventional tissue resection (0.9 vs 0.6 mm, p <0.01). 80 W KTP laser vaporization: bloodless ablative procedure, but more time-consuming

65. Uses a very high powered green laser and a thin, flexible fiber

69. Summary Minimally invasive therapies for the treatment of BPH has the advantages such as less blood loss, less occurrence of hyponatremia, quicker recovery, and reduced risk of urethral stricture. However, it also has the disadvantages such as long-lasting bladder irritation owing to higher temperature during therapy and possible longer catheterization period due to swelling of the prostate. It is still too early to make a definitive conclusion concerning the future role of these minimally invasive therapies for the treatment of BPH.