Minimally Invasive Treatment for Prostate Diseases by David A. Corral, MD, FACS

As the population ages, disorders of the prostate, both benign and cancerous, are becoming more common. For example up to 70% of men in their seventies will have at least some difficulty with an enlarged prostate. In the past, prostate diseases have been the source of considerable suffering for many men. However, as technology advances, the treatment landscape for these diseases has been rapidly evolving. The emphasis today in medicine is on minimally invasive methods of accomplishing a cure or relief of symptoms.

Both medical and surgical treatments have become more focused and specific, and as a result have become less taxing on the patient. Specifically, the combined use of advanced laparoscopic and radiologic techniques with newer methods of removing or ablating tissue has afforded treatments with far less pain, bleeding and a much more rapid recovery. Today, there are many different treatment options for patients diagnosed with either benign enlargement of the prostate or prostate cancer. In this article, I'd like to discuss some of the more recently developed minimally invasive alternatives.

Enlarged Prostate/Benign Prostatic Hyperplasia

Enlarged Prostate or BPH (Benign Prostatic Hyperplasia) is a very common noncancerous condition in which the prostate gland slowly grows over time, producing pressure on the urethra, restricting the flow of urine.

Common Symptoms of enlarged prostate include:

• Frequent urination, especially at night
  
• Sudden need to urinate
  
• Difficulty beginning urination
  
• Pain or burning
  
• Feeling that your bladder never completely empties
  
• Dribbling or leaking
  
• Weak urine stream
  

Most men will seek medical attention for these symptoms when they become severe enough to interfere with their lifestyle, causing them to avoid work or leisure activities. Men often complain that the frequency and urgency of urination forces them to stop at every restroom along the road or keeps them from completing everyday tasks. Often, frequent trips to the bathroom at night can prevent a man from getting a good night's sleep. In severe cases, when a man has become unable to pass his urine at all, a catheter must be placed to drain the bladder.

When medications are not sufficient to keep a man's symptoms in check, consideration is given to surgical therapy. In past decades, the traditional surgical method known as a transurethral resection of the prostate, or TURP, involved visualizing the prostate through a rigid telescope, or cystoscope, typically under a general anesthesia and resecting the tissue using an electric wire. This usually achieved good results, but there was a price to be paid. Because it caused bleeding, the patient would remain in the hospital for a few days and have a catheter for approximately a week. Fortunately, today there are less invasive alternatives which can achieve the same result.

A. Photoselective Vaporization of the Prostate (PVP)
One relatively noninvasive means of removing the prostate tissue that obstructs the flow of urine is known as photoselective vaporization of the prostate (PVP), also known as GreenLight(tm) Laser Therapy. This method takes advantage of the ability of a powerful laser to literally vaporize tissue at a very precise depth. Because the laser energy is absorbed by the pigment in blood, it seals off small blood vessels at the same time the prostate tissue is being vaporized. As a result there is virtually no bleeding and the patient does not absorb irrigation fluid, as can be the case during the older TURP method. Because of this, the surgeon is able to resect the blocking tissue more precisely and more effectively.

Because visualization during the procedure is greatly improved, and due to the precision of the laser, this is a very safe procedure. Postoperative urinary incontinence (loss of control of urine) does not occur after PVP, as the muscle that holds back the urine, or urinary sphincter, is preserved during the resection. Likewise, sexual potency is maintained as the nerves that are involved in sexual function are not affected. Furthermore, as the PVP technique is relatively noninvasive, it can usually be performed under moderate sedation as an outpatient. The procedure takes roughly 30 to 90 minutes. Patients are sent home the same day almost always without a catheter. After the procedure, many patients will notice some irritation when they pass their urine and/or urinary frequency, but this typically resolves quickly in a matter of days. Because the obstructing tissue is actually removed during the PVP, patients will typically notice an immediate improvement in the strength of their urinary stream and a rapid improvement in their symptoms. Over 200,000 of these procedures have been performed worldwide to date. I have treated over 300 patients using the PVP method and I've been very impressed and happy with the results.



The above pictures demonstrate how the PVP method removes obstructing prostate tissue and how the channel remains open long term, allowing improved, more effective emptying of the bladder.

B. Transurethral Microwave Therapy (TUMT)
Another noninvasive method for the treatment of BPH, known as transurethral microwave therapy or TUMT, falls into the category of thermotherapy. It takes advantage of the ability of microwave energy transmitted through a specialized catheter to warm up the inside of the enlarged prostate to a temperature which will cause the gland to later shrink, thus relieving the pressure on the urethra that causes obstruction. During the procedure, a computer precisely controls the amount and duration of microwave energy that is delivered to the prostate. TUMT is performed in the office using local anesthetic. The treatment typically takes between 30 and 60 minutes. Afterward a catheter is left in place usually for two days until the swelling in the prostate has subsided. Patients resume their usual activities immediately, and there is no negative effect on urinary incontinence or potency. As with other methods of treatment, patients may experience some urinary urgency and burning, but this is typically mild and well tolerated. Improvement in symptoms is seen within 12 weeks of the procedure, as the prostate tissue shrinks away. The TUMT procedure is best suited for patients with significant BPH symptoms whose prostate gland is not extremely large. Patients with larger glands would usually benefit more from PVP. Your urologists can determine which treatment method is best suited for you based on his physical exam and the severity of your symptoms.

A. Prostate Brachytherapy or "Seeds"
Brachytherapy involves placing a radioactive source directly into the prostate gland under ultrasound guidance. Modern techniques now allow us to deposit very small pellets about half the size of a grain of rice, commonly referred to as "seeds" that contain a source of radiation, usually iodine-125 or palladium-103. This has the advantage of delivering a higher dose of radiation to the cancer within the prostate and less radiation to the surrounding organs. As a result, the patient experiences fewer gastrointestinal and urologic side effects. This procedure combines the expertise of both a urologist and a radiation oncologist to achieve the best outcome. Computer modeling is used to determine the optimum radiation dose and the proper number of "seeds" to be placed, based on the size of the prostate. The treatment itself is performed in an outpatient setting under either a general or regional anesthetic. During the procedure, the "seeds" are deposited under ultrasound guidance using fine needles. Because no incision is used, there is very little pain and patients are discharged home the same day to resume their usual activities. The success rate for this procedure is very high. Approximately 85% of patients who start off with a low grade, small volume cancer will have a low or undetectable PSA level at 15 years after brachytherapy.

The radiation given off by the seeds will naturally decay over time, such that it is essentially gone after 2 to 3 months. Some patients may have concerns about the possibility of exposing family members to radiation during that period. They can be reassured that the radiation is given off only over a distance of a foot or two, and that other people in their proximity are not being exposed. Nevertheless, as an added margin of safety, men are advised not to hold a baby on their lap or have direct contact with pregnant women for three months afterward.

B. Cryosurgical Ablation of the Prostate
Another method of destroying cancerous tissue known as cryosurgical ablation literally freezes prostate cells. This kills the cells by several means including destroying the cell membrane, autodestruction of the cancer cell and cutting off its blood supply.

During the procedure, the surgeon inserts needles into the prostate gland through the area between the scrotum and anus. There is no incision. The surgeon may insert up to 14 needles under ultrasound guidance. The latest generation of cryotherapy uses ultra-thin needles to produce iceballs of extreme sub-zero temperatures. These needles are specially equipped to circulate liquid helium and argon in order to alternatively produce very cold and very warm temperatures. Ultrasound is then used to monitor the freezing process, which is used with great precision to destroy the entire prostate including cancerous tissue. The temperature within the prostate is lowered to - 40 degrees Centigrade for several minutes. During the procedure, a special warming device is used to protect the urethra.

In most cases, the procedure takes less than two hours. Experience with the cryotherapy procedure shows minimal to no pain, and patients recover quickly. The patient usually goes home on the same day of the procedure or the following day.

Cryosurgery can be used as primary therapy for nearly anyone with prostate cancer, but, in general, it is reserved for 2 types of patients: a.) those patients with a relatively aggressive cancer as demonstrated by a high grade on their biopsy and b.) those patients who have hade previous radiation therapy, but the cancer has returned. In a study from October 1994 to March 2005, doctors reported on 193 patients that had recurrent prostate cancer following radiation treatment. Of the 193 patients, 156 men were doing well with a PSA level of less than 10. Another 10-year study followed 963 patients. After 10 years, 70% of patients were disease free and 85% of patients had a negative biopsy. While this method is very effective, it is also very safe. Incontinence rates are low at only 1 to 7%, but impotence will occur in nearly all patients after the procedure.

Conclusion