SMITHs General Urology 6th ed Neoplasms of the Prostate Gland - Joseph C. Prest ! Jr!

M" INT#$"UCTI$N The prostate gland s the male organ most %ommonly affl %ted & th e ther 'en gn or mal gnant neoplasms. It %ompr ses the most pro( mal aspe%t of the )rethra. *natom %ally t res des n the tr)e pel+ s! separated from the p)' % symphys s anter orly 'y the retrop)' % spa%e ,spa%e of #et- )s.. The poster or s)rfa%e of the prostate s separated from the re%tal amp)lla 'y "enon+ ll ers/ fas% a. The 'ase of the prostate s %ont n)o)s & th the 'ladder ne%0! and the ape( of the prostate rests on the )pper s)rfa%e of the )rogen tal d aphragm. 1aterally! the prostate s related to the le+ator an m)s%)lat)re. Its arter al 'lood s)pply s der +ed from 'ran%hes of the nternal l a% artery , nfer or +es %al and m ddle re%tal arter es.. 2eno)s dra nage s + a the dorsal +eno)s %omple(! &h %h re%e +es the deep dorsal +e n of the pen s and +es %al 'ran%hes 'efore dra n ng nto the nternal l a% +e ns. Inner+at on s from the pel+ % ple()s. The normal prostate meas)res 3-4 %m at the 'ase! 4-6 %m n %ephalo%a)dad! and 5-3 %m n anteroposter or d mens ons. M%Neal has pop)lar -ed the %on%ept of -onal anatomy of the prostate. Three d st n%t -ones ha+e 'een dent f ed ,6 g)re 55-7.. The per pheral -one a%%o)nts for 89: of the +ol)me of the yo)ng ad)lt prostate! the %entral -one a%%o)nts for 5;:! and the trans t on -one a%%o)nts for ;:. These anatom % -ones ha+e d st n%t d)%tal systems ')t! more mportant! are d fferent ally affl %ted & th neoplast % pro%esses. S (ty to 89 per%ent of %ar% nomas of the prostate ,CaP. or g nate n the per pheral -one! 79-59: n the trans t on -one! and ;-79: n the %entral -one ,M%Neal et al! 7<==.. >en gn prostat % hyperplas a )n formly or g nates n the trans t on -one ,6 g)re 55-5.. >?NIGN P#$ST*TIC H@P?#P1*SI* ,>PH. In% den%e A ?p dem ology >PH s the most %ommon 'en gn t)mor n men! and ts n% den%e s age-related. The pre+alen%e of h stolog % >PH n a)topsy st)d es r ses from appro( mately 59: n men aged 47-;9! to ;9: n men aged ;7-69! and to o+er <9: n men older than =9. *ltho)gh %l n %al e+ den%e of d sease o%%)rs less %ommonly! symptoms of prostat % o'str)%t on are also age-related. *t age ;;! appro( mately 5;: of men report o'str)%t +e +o d ng symptoms. *t age 8;! ;9: of men %ompla n of a de%rease n the for%e and %al 'er of the r )r nary stream. # s0 fa%tors for the de+elopment of >PH are poorly )nderstood. Some st)d es ha+e s)ggested a genet % pred spos t on! and some ha+e noted ra% al d fferen%es. *ppro( mately ;9: of men )nder the age of 69 &ho )ndergo s)rgery for >PH may ha+e a her ta'le form of the d sease. Th s form s most l 0ely an a)tosomal dom nant tra t! and f rst-degree male relat +es of s)%h pat ents %arry an n%reased relat +e r s0 of appro( mately 4-fold. ?t ology The et ology of >PH s not %ompletely )nderstood! ')t t seems to 'e m)lt fa%tor al and endo%r ne %ontrolled. The prostate s %omposed of 'oth stromal and ep thel al elements! and ea%h! e ther alone or n %om' nat on! %an g +e r se to hyperplast % nod)les and the symptoms asso% ated & th >PH. ?a%h element may 'e targeted n med %al management s%hemes. $'ser+at ons and %l n %al st)d es n men ha+e %learly demonstrated that >PH s )nder endo%r ne %ontrol. Castrat on res)lts n the regress on of esta'l shed >PH and mpro+ement n )r nary symptoms. *dd t onal n+est gat ons ha+e demonstrated a pos t +e %orrelat on 'et&een le+els of free testosterone and estrogen and the +ol)me of >PH. The latter may s)ggest that the asso% at on 'et&een ag ng and >PH m ght res)lt from the n%reased estrogen le+els of ag ng %a)s ng nd)%t on of the androgen re%eptor! &h %h there'y sens t -es the prostate to free testosterone. Ho&e+er! no st)d es to date ha+e 'een a'le to demonstrate ele+ated estrogen re%eptor le+els n h)man >PH.

Pathology *s d s%)ssed a'o+e! >PH de+elops n the trans t on -one. It s tr)ly a hyperplast % pro%ess res)lt ng from an n%rease n %ell n)m'er. M %ros%op % e+al)at on re+eals a nod)lar gro&th pattern that s %omposed of +ary ng amo)nts of stroma and ep thel )m. Stroma s %omposed of +ary ng amo)nts of %ollagen and smooth m)s%le. The d fferent al representat on of the h stolog % %omponents of >PH e(pla ns! n part! the potent al respons +eness to med %al therapy. Th)s alpha-'lo%0er therapy may res)lt n e(%ellent responses n pat ents & th >PH that has a s gn f %ant %omponent of smooth m)s%le! &h le those & th >PH predom nantly %omposed of ep thel )m m ght respond 'etter to ;ared)%tase nh ' tors. Pat ents & th s gn f %ant %omponents of %ollagen n the stroma may not respond to e ther form of med %al therapy. Unfort)nately! one %annot rel a'ly pred %t respons +eness to a spe% f % therapy ,see 'elo&.. *s >PH nod)les n the trans t on -one enlarge! they %ompress the o)ter -ones of the prostate! res)lt ng n the format on of a so-%alled s)rg %al %aps)le. Th s 'o)ndary separates the trans t on -one from the per pheral -one and ser+es as a %lea+age plane for open en)%leat on of the prostate d)r ng open s mple prostate%tom es performed for >PH. Pathophys ology $ne %an relate the symptoms of >PH to e ther the o'str)%t +e %omponent of the prostate or the se%ondary response of the 'ladder to the o)tlet res stan%e. The o'str)%t +e %omponent %an 'e s)'d + ded nto the me%han %al and the dynam % o'str)%t on. *s prostat % enlargement o%%)rs! me%han %al o'str)%t on may res)lt from ntr)s on nto the )rethral l)men or 'ladder ne%0! lead ng to a h gher 'ladder o)tlet res stan%e. Pr or to the -onal %lass f %at on of the prostate! )rolog sts often referred to the B3 lo'esB of the prostate! namely! the med an and the t&o lateral lo'es. Prostat % s -e on d g tal re%tal e(am nat on ,"#?. %orrelates poorly & th symptoms! n part 'e%a)se the med an lo'e s not read ly palpa'le. The dynam % %omponent of prostat % o'str)%t on e(pla ns the +ar a'le nat)re of the symptoms e(per en%ed 'y pat ents. The prostat % stroma! %omposed of smooth m)s%le and %ollagen! s r %h n adrenerg % ner+e s)pply. The le+el of a)tonom % st m)lat on th)s sets a tone to the prostat % )rethra. Use of alpha-'lo%0er therapy de%reases th s tone! res)lt ng n a de%rease n o)tlet res stan%e. The rr tat +e +o d ng %ompla nts ,see 'elo&. of >PH res)lt from the se%ondary response of the 'ladder to the n%reased o)tlet res stan%e. >ladder o)tlet o'str)%t on leads to detr)sor m)s%le hypertrophy and hyperplas a as &ell as %ollagen depos t on. *ltho)gh the latter s most l 0ely respons 'le for a de%rease n 'ladder %ompl an%e! detr)sor nsta' l ty s also a fa%tor. $n gross nspe%t on! th %0ened detr)sor m)s%le ')ndles are seen as tra'e%)lat on on %ystos%op % e(am nat on. If left )n%he%0ed! m)%osal hern at on 'et&een detr)sor m)s%le ')ndles ens)es! %a)s ng d +ert %)la format on ,so-%alled false d +ert %)la %omposed of only m)%osa and serosa.. Cl n %al 6 nd ngs *. Symptoms *s d s%)ssed a'o+e! the symptoms of >PH %an 'e d + ded nto o'str)%t +e and rr tat +e %ompla nts. $'str)%t +e symptoms n%l)de hes tan%y! de%reased for%e and %al 'er of stream! sensat on of n%omplete 'ladder empty ng! do)'le +o d ng ,)r nat ng a se%ond t me & th n 5 h of the pre+ o)s +o d.! stra n ng to )r nate! and post-+o d dr ''l ng. Irr tat +e symptoms n%l)de )rgen%y! freC)en%y! and no%t)r a. The self-adm n stered C)est onna re de+eloped 'y the *mer %an Urolog %al *sso% at on ,*U*. s 'oth +al d and rel a'le n dent fy ng the need to treat pat ents and n mon tor ng the r response to therapy. The *U* Symptom S%ore C)est onna re ,Ta'le 557. s perhaps the s ngle most mportant tool )sed n the e+al)at on of pat ents & th >PH and s re%ommended for all pat ents 'efore the n t at on of therapy. Th s assessment fo%)ses on 8 tems that as0 pat ents to C)ant fy the se+er ty of the r o'str)%t +e or

rr tat +e %ompla nts on a s%ale of 9-;. Th)s! the s%ore %an range from 9 to 3;. * symptom s%ore of 9-8 s %ons dered m ld! =-7< s %ons dered moderate! and 59-3; s %ons dered se+ere. The relat +e d str ')t on of s%ores for >PH pat ents and %ontrol s)'De%ts s! respe%t +ely! 59: and =3: n those & th m ld s%ores! ;8: and 7;: n those & th moderate s%ores! and 53: and 5: n those & th se+ere s%ores ,M%Connell et al! 7<<4.. * deta led h story fo%)s ng on the )r nary tra%t e(%l)des other poss 'le %a)ses of symptoms that may not res)lt from the prostate! s)%h as )r nary tra%t nfe%t on! ne)rogen % 'ladder! )rethral str %t)re! or prostate %an%er. >. S gns * phys %al e(am nat on! "#?! and fo%)sed ne)rolog % e(am nat on are performed on all pat ents. The s -e and %ons sten%y of the prostate s noted! e+en tho)gh prostate s -e! as determ ned 'y "#?! does not %orrelate & th se+er ty of symptoms or degree of o'str)%t on. >PH )s)ally res)lts n a smooth! f rm! elast % enlargement of the prostate. Ind)rat on! f dete%ted! m)st alert the phys % an to the poss ' l ty of %an%er and the need for f)rther e+al)at on , e! prostate-spe% f % ant gen EPS*F! transre%tal )ltraso)nd! and ' opsy.. C. 1a'oratory 6 nd ngs * )r nalys s to e(%l)de nfe%t on or hemat)r a and ser)m %reat n ne meas)rement to assess renal f)n%t on are reC) red. #enal ns)ff % en%y may 'e o'ser+ed n 79: of pat ents & th prostat sm and &arrants )pper-tra%t mag ng. Pat ents & th renal ns)ff % en%y are at an n%reased r s0 of de+elop ng postoperat +e %ompl %at ons follo& ng s)rg %al nter+ent on for >PH. Ser)m PS* s %ons dered opt onal! ')t most phys % ans & ll n%l)de t n the n t al e+al)at on. PS*! %ompared & th "#? alone! %erta nly n%reases the a' l ty to dete%t CaP! ')t 'e%a)se there s m)%h o+erlap 'et&een le+els seen n >PH and CaP! ts )se rema ns %ontro+ers al ,see S%reen ng for CaP.. ". Imag ng Upper-tra%t mag ng , ntra+eno)s pyelogram or renal )ltraso)nd. s re%ommended only n the presen%e of %on%om tant )r nary tra%t d sease or %ompl %at ons from >PH ,eg! hemat)r a! )r nary tra%t nfe%t on! renal ns)ff % en%y! h story of stone d sease.. ?. Cystos%opy Cystos%opy s not re%ommended to determ ne the need for treatment ')t may ass st n %hoos ng the s)rg %al approa%h n pat ents opt ng for n+as +e therapy. 6. *dd t onal Tests Cystometrograms and )rodynam % prof les are reser+ed for pat ents & th s)spe%ted ne)rolog % d sease or those &ho ha+e fa led prostate s)rgery. Meas)rement of flo& rate! determ nat on of post-+o d res d)al )r ne! and press)re-flo& st)d es are %ons dered opt onal. " fferent al " agnos s $ther o'str)%t +e %ond t ons of the lo&er )r nary tra%t! s)%h as )rethral str %t)re! 'ladder ne%0 %ontra%t)re! 'ladder stone! or CaP! m)st 'e enterta ned &hen e+al)at ng men & th pres)mpt +e >PH. * h story of pre+ o)s )rethral nstr)mentat on! )rethr t s! or tra)ma sho)ld 'e el)% dated to e(%l)de )rethral str %t)re or 'ladder ne%0 %ontra%t)re. Hemat)r a and pa n are %ommonly asso% ated & th 'ladder stones. CaP may 'e dete%ted 'y a'normal t es on the "#? or an ele+ated PS* ,see 'elo&.. * )r nary tra%t nfe%t on! &h %h %an m m % the rr tat +e symptoms of >PH! %an 'e read ly dent f ed 'y )r nalys s and %)lt)reG ho&e+er! a )r nary tra%t nfe%t on %an also 'e a %ompl %at on of >PH. *ltho)gh rr tat +e +o d ng %ompla nts are also asso% ated & th %ar% noma of the 'ladder! espe% ally %ar% noma n s t)! the )r nalys s )s)ally sho&s e+ den%e of hemat)r a. 1 0e& se! pat ents & th ne)rogen % 'ladder d sorders may ha+e many of the s gns and symptoms of >PH! ')t a h story of ne)rolog % d sease! stro0e! d a'etes mell t)s! or 'a%0 nD)ry may 'e present as &ell. In add t on! e(am nat on may sho& d m n shed per neal or lo&er e(trem ty sensat on or alterat ons n re%tal sph n%ter

tone or the ')l'o%a+ernos)s refle(. S m)ltaneo)s alterat ons n 'o&el f)n%t on ,%onst pat on. m ght also alert one to the poss ' l ty of a ne)rolog % or g n. Treatment *fter pat ents ha+e 'een e+al)ated! they sho)ld 'e nformed of the +ar o)s therape)t % opt ons for >PH. It s ad+ sa'le for pat ents to %ons)lt & th the r phys % ans to ma0e an ed)%ated de% s on on the 'as s of the relat +e eff %a%y and s de effe%ts of the treatment opt ons. Spe% f % treatment re%ommendat ons %an 'e offered for %erta n gro)ps of pat ents. 6or those & th m ld symptoms ,symptom s%ore 9-8.! &at%hf)l &a t ng only s ad+ sed. $n the other end of the therape)t % spe%tr)m! a'sol)te s)rg %al nd %at ons n%l)de refra%tory )r nary retent on ,fa l ng at least one attempt at %atheter remo+al.! re%)rrent )r nary tra%t nfe%t on from >PH! re%)rrent gross hemat)r a from >PH! 'ladder stones from >PH! renal ns)ff % en%y from >PH! or large 'ladder d +ert %)la ,M%Connell et al! 7<<4.. *. Hat%hf)l Ha t ng 2ery fe& st)d es on the nat)ral h story of >PH ha+e 'een reported. The r s0 of progress on or %ompl %at ons s )n%erta n. Ho&e+er! n men & th symptomat % >PH! t s %lear that progress on s not ne+ ta'le and that some men )ndergo spontaneo)s mpro+ement or resol)t on of the r symptoms. #etrospe%t +e st)d es on the nat)ral h story of >PH are nherently s)'De%t to ' as! related to pat ent sele%t on and the type and e(tent of follo&-)p. 2ery fe& prospe%t +e st)d es address ng the nat)ral h story of >PH ha+e 'een reported. #e%ently! a large random -ed st)dy %ompared f naster de & th pla%e'o n men & th moderately to se+erely symptomat % >PH and enlarged prostates on "#? ,M%Connell et al! 7<<=.. Pat ents n the pla%e'o arm of the st)dy had a 8: r s0 of de+elop ng )r nary retent on o+er 4 years. *s ment oned a'o+e! &at%hf)l &a t ng s the appropr ate management of men & th m ld symptom s%ores ,9-8.. Men & th moderate or se+ere symptoms %an also 'e managed n th s fash on f they so %hoose. Ne ther the opt mal nter+al for follo&-)p nor spe% f % endpo nts for nter+ent on ha+e 'een def ned. >. Med %al Therapy 7. *lpha 'lo%0ersIThe h)man prostate and 'ladder 'ase %onta ns alpha-7adrenore%eptors! and the prostate sho&s a %ontra%t le response to %orrespond ng agon sts. The %ontra%t le propert es of the prostate and 'ladder ne%0 seem to 'e med ated pr mar ly 'y the s)'type a7a re%eptors. *lpha 'lo%0ade has 'een sho&n to res)lt n 'oth o'De%t +e and s)'De%t +e degrees of mpro+ement n the symptoms and s gns of >PH n some pat ents. *lpha 'lo%0ers %an 'e %lass f ed a%%ord ng to the r re%eptor sele%t + ty as &ell as the r half-l fe ,Ta'le 55-5.. Pheno(y'en-am ne and pra-os n ha+e %ompara'le eff %a%y & th respe%t to symptomat % rel ef! ')t the h gher s de-effe%t prof le of pheno(y'en-am ne! asso% ated & th ts la%0 of alpha-re%eptor spe% f % ty! pre%l)des ts )se n >PH pat ents. "ose t trat on s ne%essary & th pra-os n! & th typ %al therapy started at 7 mg at 'edt me for 3 n ghts! then n%reased to 7 mg t& %e a day! &h %h s t trated )p to 5 mg t& %e a day f ne%essary. *t h gher doses! l ttle add t onal symptomat % mpro+ement s o'ser+ed and s de-effe%t prof les &orsen. Typ %al s de effe%ts n%l)de orthostat % hypotens on! d -- ness! t redness! retrograde eDa%)lat on! rh n t s! and heada%he. 1ong-a%t ng alpha 'lo%0ers ma0e on%e-a-day dos ng poss 'le! ')t dose t trat on s st ll ne%essary. Tera-os n s n t ated at 7 mg da ly for 3 days and n%reased to 5 mg da ly for 77 days and then to ; mg per day. "osage %an 'e es%alated to 79 mg da ly f ne%essary. Therapy & th do(a-os n s started at 7 mg da ly for 8 days and n%reased to 5 mg da ly for 8 days! and then to 4 mg da ly. "osage %an 'e es%alated to = mg da ly f ne%essary. S de effe%ts are s m lar to those des%r 'ed for pra-os n. The most re%ent ad+an%e n alpha-'lo%0er therapy s related to the dent f %at on of s)'types of alpha-7-re%eptors. Sele%t +e 'lo%0ade of the a7a re%eptors! &h %h are

lo%al -ed n the prostate and 'ladder ne%0! res)lts n fe&er system % s de effe%ts ,orthostat % hypotens on! d -- ness! t redness! rh n t s! and heada%he.! th)s o'+ at ng the need for dose t trat on. Tams)los n s n t ated at 9.4 mg da ly and %an 'e n%reased to 9.= mg da ly f ne%essary. Se+eral random -ed! do)'le-'l nd! pla%e'o-%ontrolled tr als! nd + d)ally %ompar ng tera-os n! do(a-os n! or tams)los n & th pla%e'o! ha+e demonstrated the safety and eff %a%y of all of these agents. Comparat +e tr als of +ar o)s alpha 'lo%0ers are ongo ng. 5. ;a-#ed)%tase nh ' torsI6 naster de s a ;a-red)%tase nh ' tor that 'lo%0s the %on+ers on of testosterone to d hydrotestosterone. Th s dr)g affe%ts the ep thel al %omponent of the prostate! res)lt ng n a red)%t on n the s -e of the gland and mpro+ement n symptoms. S ( months of therapy are reC) red to see the ma( m)m effe%ts on prostate s -e ,59: red)%t on. and symptomat % mpro+ement. Se+eral random -ed! do)'le-'l nd! pla%e'o-%ontrolled tr als ha+e %ompared f naster de & th pla%e'o. ?ff %a%y! safety! and d)ra' l ty are &ell esta'l shed. Ho&e+er! symptomat % mpro+ement s seen only n men & th enlarged prostates ,J 49 %m3.. S de effe%ts n%l)de de%reased l ' do! de%reased eDa%)late +ol)me! and mpoten%e. Ser)m PS* s red)%ed 'y appro( mately ;9: n pat ents 'e ng treated & th f naster de! ')t nd + d)al +al)es may +ary! th)s %ompl %at ng %an%er dete%t on. * re%ent report s)ggests that f naster de therapy may de%rease the n% den%e of )r nary retent on and the need for s)rg %al nter+ent on n men & th enlarged prostates and moderate to se+ere symptoms ,M%Connell et al! 7<<=.. Ho&e+er! opt mal dent f %at on of appropr ate pat ents for prophyla%t % therapy rema ns to 'e determ ned. 3. Com' nat on therapyIThe f rst random -ed! do)'le-'l nd! pla%e'o-%ontrolled st)dy n+est gat ng %om' nat on alpha-'lo%0er and ;a-red)%tase nh ' tor therapy &as re%ently reported ,1epor et al! 7<<6.. Th s &as a fo)r-arm 2eterans *dm n strat on Cooperat +e Tr al %ompar ng pla%e'o! f naster de alone! tera-os n alone! and %om' nat on f naster de and tera-os n. $+er 7599 pat ents part % pated! and s gn f %ant de%reases n symptom s%ore and n%reases n )r nary flo& rates &ere seen only n the arms %onta n ng tera-os n. Ho&e+er! one m)st note that enlarged prostates &ere not an entry %r ter onG n fa%t! prostate s -e n th s st)dy &as m)%h smaller than that n pre+ o)s %ontrolled tr als )s ng f naster de ,35 +ers)s ;5 %m3.. *dd t onal %om' nat on therapy tr als are ongo ng. 4. PhytotherapyIPhytotherapy refers to the )se of plants or plant e(tra%ts for med % nal p)rposes. The )se of phytotherapy n >PH has 'een pop)lar n ?)rope for years! and ts )se n the Un ted States s gro& ng as a res)lt of pat ent-dr +en enth)s asm. Se+eral plant e(tra%ts ha+e 'een pop)lar -ed! n%l)d ng the sa& palmetto 'erry! the 'ar0 of Pyge)m afr %an)m! the roots of ?%h na%ea p)rp)rea and Hypo( s rooper ! pollen e(tra%t! and the lea+es of the trem'l ng poplar. The me%han sms of a%t on of these phytotherap es are )n0no&n! and the eff %a%y and safety of these agents ha+e not 'een tested n m)lt %enter! random -ed! do)'le-'l nd! pla%e'o-%ontrolled st)d es. C. Con+ent onal S)rg %al Therapy 7. Trans)rethral rese%t on of the prostate ,TU#P.IN nety-f +e per%ent of s mple prostate%tom es %an 'e done endos%op %ally. Most of these pro%ed)res n+ol+e the )se of a sp nal anesthet % and reC) re a 7- to 5-day hosp tal stay. Symptom s%ore and flo& rate mpro+ement & th TU#P s s)per or to that of any m n mally n+as +e therapy. The length of hosp tal stay of pat ents )ndergo ng TU#P! ho&e+er! s greater. M)%h %ontro+ersy re+ol+es aro)nd poss 'le h gher rates of mor' d ty and mortal ty asso% ated & th TU#P n %ompar son & th those of open s)rgery! ')t the h gher rates o'ser+ed n one st)dy &ere pro'a'ly related to more s gn f %ant %omor' d t es n the TU#P pat ents than n the pat ents )ndergo ng open s)rgery. Se+eral other st)d es %o)ld not %onf rm the d fferen%e n mortal ty &hen res)lts &ere %ontrolled for age and %omor' d t es. # s0s of TU#P n%l)de retrograde eDa%)lat on ,8;:.! mpoten%e ,;-79:.! and n%ont nen%e ,K 7:.. Compl %at ons n%l)de 'leed ng! )rethral str %t)re or 'ladder ne%0 %ontra%t)re! perforat on of the prostate %aps)le & th e(tra+asat on! and f se+ere! TU# syndrome res)lt ng from a hyper+olem %! hyponatrem % state d)e to a'sorpt on of the hypoton % rr gat ng sol)t on. Cl n %al man festat ons of the TU# syndrome n%l)de na)sea!

+om t ng! %onf)s on! hypertens on! 'rady%ard a! and + s)al d st)r'an%es. The r s0 of the TU# syndrome n%reases & th rese%t on t mes o+er <9 m n. Treatment n%l)des d )res s and! n se+ere %ases! hyperton % sal ne adm n strat on. 5. Trans)rethral n% s on of the prostateIMen & th moderate to se+ere symptoms and a small prostate often ha+e poster or %omm ss)re hyperplas a ,ele+ated 'ladder ne%0.. These pat ents & ll often 'enef t from an n% s on of the prostate. Th s pro%ed)re s more rap d and less mor' d than TU#P. $)t%omes n &ell-sele%ted pat ents are %ompara'le! altho)gh a lo&er rate of retrograde eDa%)lat on & th trans)rethral n% s on has 'een reported ,5;:.. The te%hn C)e n+ol+es t&o n% s ons )s ng the Coll ns 0n fe at the ; and 8 o/%lo%0 pos t ons. The n% s ons are started D)st d stal to the )reteral or f %es and are e(tended o)t&ard to the +er)montan)m. 3. $pen s mple prostate%tomyIHhen the prostate s too large to 'e remo+ed endos%op %ally! an open en)%leat on s ne%essary. Hhat %onst t)tes Btoo largeB s s)'De%t +e and & ll +ary depend ng )pon the s)rgeon/s e(per en%e & th TU#P. Glands o+er 799 g are )s)ally %ons dered for open en)%leat on. $pen prostate%tomy may also 'e n t ated &hen %on%om tant 'ladder d +ert %)l)m or a 'ladder stone s present or f dorsal l thotomy pos t on ng s not poss 'le. $pen prostate%tom es %an 'e done & th e ther a s)prap)' % or retrop)' % approa%h. * s mple s)prap)' % prostate%tomy s performed trans+es %ally and s the operat on of %ho %e n deal ng & th %on%om tant 'ladder pathology. *fter the 'ladder s opened! a sem % r%)lar n% s on s made n the 'ladder m)%osa! d stal to the tr gone. The d sse%t on plane s n t ated sharply! and then 'l)nt d sse%t on & th the f nger s performed to remo+e the adenoma. The ap %al d sse%t on sho)ld 'e done sharply to a+o d nD)ry to the d stal sph n%ter % me%han sm. *fter the adenoma s remo+ed! hemostas s s atta ned & th s)t)re l gat)res! and 'oth a )rethral and a s)prap)' % %atheter are nserted 'efore %los)re. In a s mple retrop)' % prostate%tomy! the 'ladder s not entered. #ather! a trans+erse n% s on s made n the s)rg %al %aps)le of the prostate! and the adenoma s en)%leated as des%r 'ed a'o+e. $nly a )rethral %atheter s needed at the end of the pro%ed)re. ". M n mally In+as +e Therapy 7. 1aser therapyIMany d fferent te%hn C)es of laser s)rgery for the prostate ha+e 'een des%r 'ed. T&o ma n energy so)r%es of lasers ha+e 'een )t l -edINdL@*G and holm )mL@*G. Se+eral d fferent %oag)lat on ne%ros s te%hn C)es ha+e 'een des%r 'ed. Trans)rethral laser- nd)%ed prostate%tomy ,TU1IP. s done & th transre%tal )ltraso)nd g) dan%e. The TU1IP de+ %e s pla%ed n the )rethra! and transre%tal )ltraso)nd s )sed to d re%t the de+ %e as t s slo&ly p)lled from the 'ladder ne%0 to the ape(. The depth of treatment s mon tored & th )ltraso)nd. Most )rolog sts prefer to )se + s)ally d re%ted laser te%hn C)es. 2 s)al %oag)lat +e ne%ros s te%hn C)es ha+e 'een pop)lar -ed 'y Ma'al n. Under %ystos%op % %ontrol! the laser f 'er s p)lled thro)gh the prostate at se+eral des gnated areas! depend ng )pon the s -e and %onf g)rat on of the prostate. 6o)r C)adrant and se(tant approa%hes ha+e 'een des%r 'ed for lateral lo'es! & th add t onal treatments d re%ted at enlarged med an lo'es. Coag)lat +e te%hn C)es do not %reate an mmed ate + s)al defe%t n the prostat % )rethra! ')t rather t ss)e s slo)ghed o+er the %o)rse of se+eral &ee0s and )p to 3 months follo& ng the pro%ed)re. 2 s)al %onta%t a'lat +e te%hn C)es are more t me-%ons)m ng pro%ed)res 'e%a)se the f 'er s pla%ed n d re%t %onta%t & th the prostate t ss)e! &h %h s +apor -ed. *n mmed ate defe%t s o'ta ned n the prostat % )rethra! s m lar to that seen d)r ng TU#P. Interst t al laser therapy pla%es f 'ers d re%tly nto the prostate! )s)ally )nder %ystos%op % %ontrol. *t ea%h p)n%t)re! the laser s f red! res)lt ng n s)'m)%osal %oag)lat +e ne%ros s. Th s te%hn C)e may res)lt n fe&er rr tat +e +o d ng symptoms! 'e%a)se the )rethral m)%osa s spared and prostate t ss)e s resor'ed 'y the 'ody rather than slo)ghed.

*d+antages of laser s)rgery n%l)de ,7. m n mal 'lood loss! ,5. rare nstan%es of TU# syndrome! ,3. a' l ty to treat pat ents re%e + ng ant %oag)lat on therapy! and ,4. a' l ty to 'e done as an o)tpat ent pro%ed)re. " sad+antages n%l)de ,7. la%0 of a+a la' l ty of t ss)e for patholog % e(am nat on! ,5. longer postoperat +e %atheter -at on t me! ,3. more rr tat +e +o d ng %ompla nts! and ,4. h gh %ost of laser f 'ers and generators. 1arge-s%ale! m)lt %enter! random -ed st)d es & th long-term follo&-)p are needed to %ompare laser prostate s)rgery & th TU#P and other forms of m n mally n+as +e s)rgery. 5. Trans)rethral ele%tro+apor -at on of the prostateITrans)rethral ele%tro+apor -at on )ses the standard rese%tos%ope ')t repla%es a %on+ent onal loop & th a +ar at on of a groo+ed roller'all. H gh %)rrent dens t es %a)se heat +apor -at on of t ss)e! res)lt ng n a %a+ ty n the prostat % )rethra. >e%a)se the de+ %e reC) res slo&er s&eep ng speeds o+er the prostat % )rethra! and the depth of +apor -at on s appro( mately one-th rd of a standard loop! the pro%ed)re )s)ally ta0es longer than a standard TU#P. 1ong-term %omparat +e data are needed. 3. Hypertherm aIM %ro&a+e hypertherm a s most %ommonly del +ered & th a trans)rethral %atheter. Some de+ %es %ool the )rethral m)%osa to de%rease the r s0 of nD)ry. Ho&e+er! f temperat)res do not e(%eed 4; NC! %ool ng s )nne%essary. Impro+ement n symptom s%ore and flo& rate s o'ta ned! ')t as & th laser s)rgery! larges%ale! random -ed st)d es & th long-term follo&-)p are needed to assess d)ra' l ty and %ost-effe%t +eness. 4. Trans)rethral needle a'lat on of the prostateITrans)rethral needle a'lat on )ses a spe% ally des gned )rethral %atheter that s passed nto the )rethra. Interst t al rad ofreC)en%y needles are then deployed from the t p of the %atheter! p er% ng the m)%osa of the prostat % )rethra. The )se of rad o freC)en% es to heat the t ss)e res)lts n a %oag)lat +e ne%ros s. Th s te%hn C)e s not adeC)ate treatment for 'ladder ne%0 and med an lo'e enlargement. S)'De%t +e and o'De%t +e mpro+ement n +o d ng o%%)rs! ')t as ment oned a'o+e! %omparat +e long-term random -ed st)d es are la%0 ng. ;. H gh- ntens ty fo%)sed )ltraso)ndIH gh- ntens ty fo%)sed )ltraso)nd s another means of perform ng thermal t ss)e a'lat on. * spe% ally des gned! d)al-f)n%t on )ltraso)nd pro'e s pla%ed n the re%t)m. Th s pro'e allo&s transre%tal mag ng of the prostate and also del +ers short ')rsts of h gh- ntens ty fo%)sed )ltraso)nd energy! &h %h heats the prostate t ss)e and res)lts n %oag)lat +e ne%ros s. >ladder ne%0 and med an lo'e enlargement are not adeC)ately treated & th th s te%hn C)e. *ltho)gh ongo ng %l n %al tr als demonstrate some mpro+ement n symptom s%ore and flo& rate! the d)ra' l ty of response s )n0no&n. 6. Intra)rethral stentsIIntra)rethral stents are de+ %es that are endos%op %ally pla%ed n the prostat % fossa and are des gned to 0eep the prostat % )rethra patent. They are )s)ally %o+ered 'y )rothel )m & th n 4-6 months after nsert on. These de+ %es are typ %ally )sed for pat ents & th l m ted l fe e(pe%tan%y &ho are not deemed to 'e appropr ate %and dates for s)rgery or anesthes a. H th the ad+ent of other m n mally n+as +e te%hn C)es reC) r ng m n mal anesthes a ,%ons% o)s sedat on or prostat % 'lo%0s.! the r appl %at on has 'e%ome more l m ted. 8. Trans)rethral 'alloon d lat on of the prostateI>alloon d lat on of the prostate s performed & th spe% ally des gned %atheters that ena'le d lat on of the prostat % fossa alone or the prostat % fossa and 'ladder ne%0. The te%hn C)e s most effe%t +e n small prostates ,K 49 %m3.. *ltho)gh t may res)lt n mpro+ement n symptom s%ore and flo& rates! the effe%ts are trans ent and the te%hn C)e s rarely )sed today.