The evolution of photoselective vaporization prostatectomy (PVP): advancing the surgical treatment of benign prostatic hyperplasia.
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Animals↗
Biomedical subjects
Alexis E Te
Publications and source records attributed to Alexis E Te.
Refractory overactive bladder in men: update on novel therapies.
Overactive bladder (OAB) in men is an entity that may be challenging to diagnose and treat, especially in the presence of bladder outlet obstruction. The application of oral medical treatments of lower urinary tract symptoms attributed to benign prostatic hyperplasia has traditionally utilized alpha-adrenergic blockers and 5alpha-reductase inhibitors. After failure of oral medical therapies, surgical options are traditionally offered. Even after surgical options are successful, lower urinary tract symptoms that are secondary to OAB persist. These patients merit a trial of antimuscarinic drugs. Additionally, certain patients with concomitant bladder outlet obstruction who have not been surgically relieved can still merit a trial of antimuscarinic drugs without significant risk of developing urinary retention. When these oral antimuscarinic drugs fail, options still remain for treating men with refractory OAB. Successful application of various diagnostic approaches and the initiation of conservative options as well as other options, such as neuromodulation for refractory urgency and urge incontinence, can help the patient. Finally, emerging data support the use of intradetrusor injections of botulinum toxin for refractory OAB.
Cholinergic Antagonists↗
Is there a role for urodynamics in chronic nonbacterial prostatitis?
The etiology of chronic nonbacterial chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is unclear. That may be why treatment with antibiotics and anti-inflammatory drugs often fail. The use of urodynamic testing in evaluating any patient with both pelvic/perineal pain coexistent with voiding symptoms can help identify voiding dysfunction. If identified, urodynamic voiding disorders, such as bladder neck obstruction and pseudodyssynergia, should be specifically treated to ameliorate symptoms. Through more research of nonbacterial CP/CPPS, we will be able to further define the successful role of videourodynamics in men with this disease.
Chronic Disease↗
Urodynamic predictors of outcomes with photoselective laser vaporization prostatectomy in patients with benign prostatic hyperplasia and preoperative retention.
OBJECTIVES: To determine whether preoperative urodynamic parameters can predict the outcome in men in urinary retention and aid in counseling these men. METHODS: Forty men in urinary retention due to benign prostatic hyperplasia underwent photoselective laser vaporization prostatectomy (PVP). Preoperative urodynamic studies were used to identify the men with detrusor overactivity (DO) and impaired detrusor contractility (IDC). The International Prostate Symptom Score (IPSS), maximal flow rate, and postvoid residual urine volume were collected at 1, 3, 6, and 12 months after PVP. RESULTS: Of the 40 men, 8 (20%) had IDC and 30 had DO (75%) preoperatively. The men without preoperative DO had a significantly lower IPSS than those with preoperative DO at 1 month of follow-up. Men without preoperative IDC had a significantly lower IPSS and postvoid residual urine volume at the same point compared with men with preoperative IDC. The flow rate in men with preoperative IDC 1 and 6 months postoperatively was significantly lower than in men without preoperative IDC. CONCLUSIONS: Preoperative urodynamic parameters predict for outcome in men in urinary retention undergoing PVP. Men in urinary retention benefit from PVP with an improvement in both subjective and objective voiding function, regardless of the presence of DO or IDC. Postoperatively, patients with DO have more voiding symptoms than those without DO, and are almost twice as likely to require anticholinergics. Men without IDC have better IPSS, flow rates, and postvoid residual urine volumes compared with men with IDC. Of the 8 men with IDC, 3 required reoperation within the first year.
Humans↗
Short- and long-term efficacy of solifenacin treatment in patients with symptoms of mixed urinary incontinence.
OBJECTIVE: To evaluate urinary symptom relief in women with mixed urinary incontinence (MUI) treated for up to 52 weeks with solifenacin succinate for overactive bladder (OAB), as MUI is a complex and distressing condition reported by about a third of incontinent women, and with confirmed efficacy in OAB-related urge incontinence, anticholinergic agents are a reasonable therapeutic option for such women. PATIENTS AND METHODS: Patients with OAB (mean of > or = 8 voids/24 h, plus > or = 1 incontinence episode or > or = 1 urgency episode/24 h) were pooled from four studies. A subgroup of 1041 patients reporting MUI at baseline were evaluated over 12 weeks in a double-blind, placebo-controlled study, and up to a further 40 weeks in 433 in an open-label solifenacin treatment (5 mg and 10 mg). Voiding frequency, episodes of incontinence and urgency, and volume voided per void, were collected from voiding diaries completed during the 3 days before each study visit. RESULTS: Patients with a history of MUI treated with solifenacin for up to 12 weeks had statistically significant reductions in voiding frequency and episodes of incontinence and urgency vs placebo. In all, 43% and 49% (at 5 mg and 10 mg, respectively) of patients with a history of MUI regained continence after 12 weeks, vs 33% with placebo. Among patients in the open-label study with mixed symptoms, 52% reported regaining continence, and 34% reported resolution of symptomatic urgency based on diary reporting at study end. Sustained improvements in quality of life and high satisfaction ratings accompanied symptom improvements. CONCLUSIONS: Significant reductions in OAB-related frequency, incontinence and urgency were reported after 12 weeks of solifenacin treatment in patients with a history of MUI. Symptom improvement in this subgroup was maintained during long-term treatment. These findings support the therapeutic potential of solifenacin for treating symptoms of MUI and the need to re-evaluate classically defined MUI.
Adolescent↗
Impact of prostate-specific antigen level and prostate volume as predictors of efficacy in photoselective vaporization prostatectomy: analysis and results of an ongoing prospective multicentre study at 3 years.
UNLABELLED: In a multicentre study from the USA, 3-year results of the high-power KTP laser prostatectomy are presented. The authors used preoperative PSA level as a marker of prostate volume and assessed its potential predictive value on the level of clinical efficacy for treating symptomatic BPH. They found that the overall results from the technique were positive and durable, and suggested that there was a significant difference in efficacy between patients presenting with a total PSA of <6 or >6 ng/mL. Many patients who have had a radical prostatectomy are followed for a prolonged period and several observations are presented from an Italian study of urinary incontinence. The authors present their detailed results, finding a considerable trend in incontinence and anastomotic stricture, which decreased over time. OBJECTIVE: To report the 3-year results and analyse whether total prostate-specific antigen (tPSA) levels and prostate volume before treatment can predict the level of clinical efficacy of photoselective vaporization prostatectomy (PVP) for treating obstructive benign prostatic disease, as high-power potassium-titanyl-phosphate (KTP) laser prostatectomy was previously shown to be safe and to efficiently vaporize prostatic adenoma secondary to benign prostatic hyperplasia (BPH), with minimal bleeding and morbidity. PATIENTS AND METHODS: From October 2001 to January 2003, 139 men (mean age 67.7 years, sd 8.7) diagnosed with obstructive lower urinary tract symptoms secondary to BPH, had PVP with an average 80 W of KTP laser energy, at six investigational centres. A subanalysis evaluating each patient for tPSA and prostate volume before PVP was conducted, with a long-term assessment of the primary efficacy outcomes at 3 years after PVP. Each patient was assigned to one of two subgroups according to the tPSA level (group 1, < or = 6.0 ng/mL; group 2 > or = 6.1 ng/mL) and evaluated separately. Each subgroup was assessed for changes from baseline in American Urological Symptom Index (AUA SI) score, quality of life (QoL) score, peak urinary flow rate (Q(max)), prostate volume, and postvoid residual urine volume (PVR) at 1, 2 and 3 years after PVP. RESULTS: All tPSA subgroups had a sustained improvement in all efficacy outcomes maintained through the 3 years. There was a statistically significant difference in the level of improvement between groups 1 and 2 (P < 0.05) in AUA SI and Q(max) at 1, 2 and 3 years. The mean (sd) prostate volume for group 1 was 48.3 (16.7) mL (87 men), and was 83.1 (30.6) mL (52 men) in group 2. The mean percentage improvement in the AUA SI at 1, 2 and 3 years in group 1 and 2, respectively, was 86%, 92% and 85%, and 69%, 74% and 76%; the corresponding percentage improvement in Q(max) was 194%, 185% and 179%, and 124%, 145% and 139%, respectively. Overall treatment efficacy in all patients evaluated showed a mean 83%, 79%, 71% and 165% improvement in AUA SI, QoL, PVR and Q(max), respectively. Adverse events were minimal and the re-treatment rate was 4.3%. CONCLUSIONS: These results suggest that there is a significant difference in efficacy in patients with a tPSA of < or = 6.0 ng/mL or > or = 6.1 ng/mL before PVP. However, the overall results achieved with PVP were very positive and durable to 3 years, irrespective of tPSA level and prostate volume.
Aged↗
Athermal Robotic Technique of prostatectomy in patients with large prostate glands (>75 g): technique and initial results.
OBJECTIVE: To report our experience with robotic radical prostatectomy (rRP) for prostate glands of >75 g, as this technique is developing rapidly. PATIENTS AND METHODS: Between January 2005 and November 2005, 30 men with prostates of >75 g had rRP. Their clinicopathological and operative data were reviewed. Technical considerations for successful rRP in patients with large glands are discussed, including the importance of surgical exposure and multiple traction sutures. RESULTS: The mean (range) specimen weight was 116.1 (75.3-346.0) g, the patient age 65.0 (56-72) years, the body mass index 28.4 (21-41) kg/m2, the preoperative International Prostate Symptom Score 10 (0-32), and the prostate-specific antigen (PSA) level 7.54 (1.9-20.1) ng/mL. The clinical stage was T1c in 26 men and T2a in four. The biopsy Gleason scores were 3 + 3 = 6 in 25 men, 3 + 4 = 7 in four and 4 + 3 = 7 in one. The mean (range) estimated blood loss was 208 (100-600) mL and the operative duration 193 (150-270) min. The cancer was organ-confined in all patients and all surgical margins were negative. The mean (range) duration of indwelling catheterization was 12.7 (11-14) days. There were no complications during or after rRP, and the PSA level was undetectable in all patients after surgery. CONCLUSIONS: RP for patients with large prostates is technically challenging. The robotic approach does not appear to compromise oncological control. We show the feasibility of rRP for men with large glands.
Aged↗
The Next Generation in Laser Treatments and the Role of the GreenLight High-Performance System Laser.
Lasers have evolved over the past decade, with technical refinements that have resulted in a procedure that can achieve transurethral-like results in a safe and efficacious manner. The physics and characteristics of the laser light, such as wavelength and power densities, influence efficiency of treatment and safety profiles of various laser techniques and systems. The currently commercially available 80-W potassium-titanyl-phosphate laser used for photoselective vaporization of the prostate gland in men with lower urinary tract symptoms and benign prostatic hyperplasia has been shown to be a safe and effective therapeutic alternative for a wide spectrum of prostate sizes and configurations. Refinements based on clinical experience as well as progress in available technologies have produced an advanced system with improvements in beam quality and an increase in power to provide an increase in vaporization efficiency and flexibility in technique. The refinements require adjustments to current technique. The advanced technological developments enhance the utility of this laser for application in benign prostatic hyperplasia and urology.
Journal Article↗
Saw palmetto and finasteride in the treatment of category-III prostatitis/chronic pelvic pain syndrome.
Chronic nonbacterial prostatitis/chronic pelvic pain syndrome is a common entity for which a standardized management has not been established. Patients often have a significant symptom complex and impact on quality of life, but very little is known about the efficacy of second- and third-line treatments, such as the use of herbal supplements. Many treatments studied in recent literature include antibiotics, alpha-blockade, anti-inflammatory agents, and cognitive behavioral interventions such as biofeedback and psychotherapy.
5-alpha Reductase Inhibitors↗
Overactive bladder in the male patient: epidemiology, etiology, evaluation, and treatment.
The urologist's approach to the diagnosis and treatment of lower urinary tract symptoms (LUTS) in male patients has changed significantly over the past decade. Advances in the basic science arena combined with a wealth of clinical data have pointed to the importance of bladder pathophysiology in the development of urinary symptoms. Historically, men with LUTS were diagnosed with "prostatism," an all-encompassing term that includes both voiding and storage symptoms that may or may not be related to prostatic obstruction. Parallel to the scientific advances in the field, the urologic lexicon began to evolve and has allowed us to more specifically describe, and therefore investigate and treat, different aspects of male LUTS. It is now well recognized that many men suffer from storage symptoms that may be more related to bladder dysfunction than to prostatic obstruction. It will be critical to integrate our knowledge of prostatic growth and obstruction, the bladder response to outlet obstruction, environmental and lifestyle factors, and age-related changes to fully understand the complex pathophysiology of male LUTS, specifically overactive bladder syndrome.
Algorithms↗
Photoselective laser vaporization prostatectomy in men receiving anticoagulants.
BACKGROUND AND PURPOSE: Photoselective laser vaporization prostatectomy (PVP) with a high-power KTP laser is a hemostatic procedure for men with symptomatic benign prostatic hyperplasia (BPH). This study demonstrates the feasibility of PVP in men who are receiving anticoagulants. PATIENTS AND METHODS: Men treated with PVP for symptomatic BPH between July 2002 and September 2003 who were receiving anticoagulants (N=24) were reviewed retrospectively. Their mean age was 75 years, and the mean prostate volume was 82 cc (range 34-164 cc). Nine men (38%) were in retention, eight (33%) had had a myocardial infarction, seven (29%) had had a cerebrovascular accident, and seven had peripheral vascular disease. Of these men, 8 were on warfarin, 2 on clopidogrel, and 14 on aspirin. Men on warfarin discontinued the drug 2 days prior to surgery and restarted it the day after. The other two drugs were not discontinued. The PVP was performed with an 80 W KTP side-firing laser (Laserscope Greenlight PV) through a 23F continuous-flow cystoscope with normal saline as the irrigant. RESULTS: The mean operative time was 101 minutes. No transfusions were required. Most (22; 92%) of the men were discharged without a catheter. The serum hematocrit did not change significantly (40.0% to 38.3%). The International Prostate Symptom Score decreased to 13.6, 10.9, 9.7, and 9.5 at 1, 3, 6, and 12 months from a mean of 18.7 preoperatively. The Qmax increased from 9.0 mL/sec preoperatively to 15.1, 16.3, 20.9, and 20.1 mL/sec at 1, 3, 6, and 12 months. No patients had clinically significant hematuria postoperatively, and none suffered clot retention. CONCLUSIONS: Photoselective laser vaporization prostatectomy is a suitable treatment option in men being treated with anticoagulants, who are at high risk for clinically significant bleeding.
Aged↗
Tolterodine extended release attenuates lower urinary tract symptoms in men with benign prostatic hyperplasia.
PURPOSE: In this open label, prospective study we determined the efficacy and tolerability of tolterodine extended release (ER) in men with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) in whom previous alpha-blocker therapy had failed. MATERIALS AND METHODS: A total of 43 consecutive men with BPH and LUTS in whom a mean of 5.7 months of alpha-blocker therapy had failed due to adverse events (11) or a lack of efficacy (32) received tolterodine ER (4 mg daily) for 6 months. Primary efficacy end points were American Urological Association symptom score, and mean daytime and nighttime micturition frequency. Secondary end points were the peak urinary flow rate, post-void residual volume, the incidence of urinary retention, total score on the erectile function domain of the International Index of Erectile Function and adverse events. RESULTS: A total of 39 men (91%) with a mean age of 61 years completed the 6-month trial. Mean 24-hour micturition frequency decreased from 9.8 to 6.3 voids and nocturia decreased from 4.1 to 2.9 episodes nightly. Significant changes in mean American Urological Association symptom scores (-6.1), the peak urinary flow rate (1.9 ml per second) and post-void residual volume (-22 ml) were also observed. Of the men 27 (63%) were potent at baseline and 29 (67%) were potent after 6 months of tolterodine ER treatment. Mean International Index of Erectile Function erectile function domain scores increased (6.9). Four men (9%) discontinued therapy because of intolerable dry mouth. There were no reports of urinary retention. CONCLUSIONS: Treatment with tolterodine ER in men with BPH and LUTS may be a reasonable therapeutic option as initial therapy or after failed treatment with alpha-blockers.
Adrenergic beta-Antagonists↗
The role of 5-alpha-reductase inhibition as monotherapy in view of the MTOPS data.
Medical treatment for the symptoms of benign prostatic hyperplasia (BPH) consists of a blockers and 5-alpha-reductase inhibitors. Data suggest that 5-alpha-reductase inhibitors can prevent progression of BPH and reduce the risk of BPH-related surgery, especially in men with large-volume prostates. Results from the largest randomized, prospective, placebo-controlled trial, the Medical Therapy of Prostatic Symptoms trial, have been presented. These results support the notion of using 5-alpha-reductase inhibitors for the prevention of BPH progression and BPH-related surgery. Furthermore, long-term 5-alpha-reductase inhibitor monotherapy, although slow in onset, is a viable therapy for symptom relief in men with mild to moderate symptoms.
5-alpha Reductase Inhibitors↗
Chronic prostatitis and sensory urgency: whose pain is it?
Difficulties encountered in diagnosing and effectively treating chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is frustrating for clinicians and patients. Scientific evidence cannot establish an exact relationship between the prostate and the symptoms of CP/CPPS, and the prostate continues to be the diagnosis of convenience in this complex syndrome in men. However, if the pain is not the prostate's, whose pain is it? A heterogeneous group of insults can result in a common neurogenic pain response, resulting in recurring pain and voiding or sexual dysfunction. To add to this dilemma, certain life-threatening diagnoses, such as carcinoma-in-situ, is in the differential diagnosis and must be excluded. Urodynamics may be useful in evaluating and treating patients whose voiding symptoms predominate. However, many patients with CP/CPPS will not have measurable abnormalities by conventional methods and likely suffer from a functional somatic syndrome that is best treated with a multimodality approach.
Chronic Disease↗
High-power potassium-titanyl-phosphate photoselective laser vaporization of prostate for treatment of benign prostatic hyperplasia in men with large prostates.
OBJECTIVES: To study the safety and efficacy of high-power potassium-titanyl-phosphate photoselective laser vaporization of the prostate in men with prostate volumes greater than 60 cm3. METHODS: A total of 64 men with symptomatic benign prostatic hyperplasia and large-volume prostates underwent photoselective laser vaporization of the prostate between May 2002 and September 2003. Medical therapy had failed in all men, and 18 presented with urinary retention. The preoperative evaluation included the maximal flow rate, postvoid residual urine volume, prostate volume, serum sodium, creatinine, and hematocrit, and International Prostate Symptom Score. Transurethral prostatectomy was performed with an 80 W potassium-titanyl-phosphate (KTP) side-firing laser system through a 23F continuous-flow cystoscope with normal saline as the irrigant. The operative time, anesthesia type, length of stay, and postoperative serum sodium, creatinine, and hematocrit were recorded. The International Prostate Symptom Score, maximal flow rate, and postvoid residual urine volume were measured at each follow-up visit. RESULTS: The mean preoperative prostate volume was 101 +/- 40 cm3. The mean operative time was 123 +/- 70 minutes. No transfusions were required. Of the 64 patients, 62 were discharged within 23 hours. The serum sodium level did not change significantly. The International Prostate Symptom Score decreased from 18.4 preoperatively to 9.9, 8.6, 7.2, and 6.7 at 1, 3, 6, and 12 months postoperatively, and the maximal flow rate increased from 7.9 mL/s preoperatively to 16.4, 16.2, 20.0, and 18.9 mL/s at 1, 3, 6, and 12 months postoperatively. The postvoid residual urine volume also decreased from 189 mL preoperatively to 78, 78, 67, and 109 mL at 1, 3, 6, and 12 months postoperatively. CONCLUSIONS: Photoselective laser vaporization of the prostate is safe and efficacious, with durable results for men with symptomatic benign prostatic hyperplasia and large-volume prostates.
Adult↗
A prospective, 1-year trial using saw palmetto versus finasteride in the treatment of category III prostatitis/chronic pelvic pain syndrome.
PURPOSE: This study was designed to assess the safety and efficacy of saw palmetto or finasteride in men with category III prostatitis/chronic pelvic pain syndrome (CP/CPPS). MATERIALS AND METHODS: A prospective, randomized, open label, 1-year study was designed to assess the safety and efficacy of saw palmetto and finasteride in the treatment of men diagnosed with CP/CPPS. Patients were randomized to finasteride (5 mg once daily) or saw palmetto (325 mg daily) for 1 year. Patients were evaluated using the National Institutes of Health Chronic Prostatitis Symptom Index, individual domains (pain, urinary symptoms, quality of life and mean pain score) and the American Urological Association Symptom Score at baseline, 3, 6 and 12 months. RESULTS: A total of 64 consecutive men 24 to 58 years old (mean age 43.2) with a diagnosis of CP/CPPS were equally randomized to the 2 treatment arms. All 64 men had previously received antibiotics (duration of 3 to 93 weeks), 52 (82%) had been on alpha-blockade. There were 61, 57 and 56 patients evaluable at 3, 6 and 12 months, respectively. At 1 year mean total National Institutes of Health Chronic Prostatitis Symptom Index score decreased from 23.9 to 18.1 in the finasteride group (p <0.003), and from 24.7 to 24.6 in the saw palmetto arm (p = 0.41). In the finasteride arm the quality of life and pain domains were significantly improved at 1 year; however, urination was not. Adverse events included headache (3 cases) in the saw palmetto group and decreased libido (2 cases) in the finasteride group. At the end of the trial 13 of 32 (41%) and 21 of 32 (66%) opted to continue saw palmetto and finasteride, respectively. CONCLUSIONS: CP/CPPS treated with saw palmetto had no appreciable long-term improvement. In contrast, patients treated with finasteride had significant and durable improvement in all various parameters except voiding. Further studies are warranted to ascertain the mechanism and reproducibility of these effects in a placebo controlled trial.
Adult↗
Photoselective vaporization of the prostate for the treatment of benign prostatic hyperplasia: 12-month results from the first United States multicenter prospective trial.
PURPOSE: We report the 1-year efficacy and safety of photoselective vaporization of the prostate (PVP) for symptomatic and obstructive benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A prospective clinical trial was performed in 139 men clinically diagnosed with symptomatic bladder outlet obstruction secondary to BPH who were enrolled and treated with a high power, 80 W, quasicontinuous wave potassium-titanyl-phosphate laser at 6 American medical centers across the country. Efficacy parameters were mean and percent changes from baseline in the American Urological Association Symptom Index (AUA-SI) score, quality of life score (QOL), peak urinary flow rate (Qmax), post-void residual urine volume (PVR) and transrectal ultrasound prostate volume measurement. Patients were evaluated 1, 3, 6 and 12 months following treatment. At each followup evaluation side effects were elicited. RESULTS: Significant improvements in AUA-SI score, QOL score, Qmax and PVR were noted as early as 1 month after PVP treatment. At 12 months the mean AUA-SI score decreased from 23.9 to 4.3 (p <0.0001) and the QOL score decreased from 4.3 to 1.1 (p <0.0001), while mean Qmax increased from 7.8 to 22.6 ml per second (p <0.0001). PVR decreased from 114.3 to 24.8 ml (p <0.0001), while the transrectal ultrasound volume reduction went from 54.6 ml at baseline to 34.4 ml. There was no significant blood loss or fluid absorption during or immediately after PVP. Complications consisted of transient hematuria, dysuria and urinary retention in 12 (8.6%), 13 (9.3%) and 7 (5%) patients, respectively. CONCLUSIONS: PVP is a unique, safe and effective outpatient modality that provides immediate symptomatic and urodynamic relief of bladder outlet obstruction secondary to BPH. Long-term followup is needed to validate further the maintenance of clinical efficacy beyond 1 year.
Aged↗
Overactive bladder and men: indications for anticholinergics.
Similar to bladder outlet obstruction (BOO), overactive bladder (OAB) symptoms are very common and increase in prevalence as men age. Whether or not OAB symptoms are thought to be secondary to BOO, the goal of treatment of symptoms should result in an improved quality of life and ultimately prevent clinical deterioration. A common dilemma when treating men with obstruction and OAB is the risk of acute urinary retention or morbidities related to increasing postvoid residuals. In this article, the relationship of OAB to BOO is examined and the role of urodynamics and data on the use of anticholinergics in men with OAB and obstruction are reviewed. An algorithm for managing men with OAB also is proposed. In men with OAB without evidence of obstruction (including OAB after treatment for BOO), first-line medical therapy with anticholinergics is indicated. However, in men with OAB and concomitant BOO, nomogram has been developed to assist in the management of patients at risk for urinary retention. Men with significant obstruction should be appropriately treated to decrease bladder outlet resistance before adding anticholinergics for the treatment of OAB.
Algorithms↗