Minimally Invasive Surgical Therapy And Lower Urinary Tract Symptoms Treatment Evidence Based Treatment

Main Category: Urology / Nephrology
Article Date: 10 Aug 2008 - 0:00 PDT

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UroToday.com - The new paradigm in the treatment of Lower Urinary Tract Symptoms (LUTS) is towards both medical management and minimally invasive surgery. LUTS is a symptom complex that includes both irritative as well as obstructive symptoms. Generally, surgical treatment is directed at the obstructive component. The "gold standard" for surgical management of bladder outlet obstruction has been and remains the TURP.

Minimally invasive surgical therapy (MIST) includes a variety of techniques that include laser ablation, thermal ablation, radiofrequency ablation, and microwave ablation of the prostate. Specific techniques change rapidly as new technology is developed and older technologies are shown to be less successful than their initial studies when used in a broader market. While there are many large and well designed trials of medical management, the trials of minimally invasive surgical therapy are relatively small, do not generally have a placebo run in, and are performed in higher risk patients, making comparison to medical management difficult. Few trials have been performed a direct comparison between medical management and MIST. However, small trials actually report data that favors MIST in terms of both IPSS and Qmax. 1,2 Norby et al demonstrated a statistically significant difference comparing TUMT vs. interstitial laser therapy vs. TURP favoring TURP.3 In Cochrane analyses comparing either TUMT or laser therapy, TURP shows an increased benefit compared to MIST (IPSS and Qmax). MIST (TUMT) in turn outperforms alpha blockers, making it a viable alternative.4,5

Patients undergoing MIST are more likely to experience dysuria, urinary retention, and reoperation than TURP.4,5

References:

1. Djavan B, Roehrborn CG, Shariat S, et al. Prospective randomized comparison of high energy transurethral microwave thermotherapy versus alpha-blocker treatment of patients with benign prostatic hyperplasia. J Urol. 1999;161:139-143
2. C G Roehrborn, Benign Prostatic Hyperplasia: An Overview Rev Urol. 2005; 7(Suppl 9): S3-S14
3. Norby, B, Nielson HV, Frimodt-Moller PC Transurethral interstitial laser coagulation of the prostate and transurethral microwave thermotherapy vs transurethral resection or incision of the prostate: results of a randomized, controlled study in patients with symptomatic benign prostatic hyperplasia , BJU, 90:853-62, 2002
4. Hoffman RM, Monga M, ElliottSP, MacDonald R, Wilt TJ Mircowave thermotherapy for benign prostatit hyperplasia, Cochrane Database Syst Rev, Oct 2007.
5. Hoffman RM, McDonald R, Wilt TJ Laser Prostatectomy for benign prostatic obstruction, Cochrane Database Syst Rev, 2004.

Presented by: Sam D. Graham, Jr., MD, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda

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