Transurethral hot-water balloon thermoablation for benign prostatic hyperplasia: patient tolerance and pathologic findings

Inhibition effects of chlorogenic acid on benign prostatic hyperplasia in mice

This study aimed to evaluate the inhibitory effects and explore mechanisms of chlorogenic acid against testosterone-induced benign prostatic hyperplasia (BPH) in mice. Benign prostatic hyperplasia model was induced in experimental groups by daily subcutaneous injections of testosterone propionate (7.5mg/kg/d) consecutively for 14 d. A total of 60 mice were randomly divided into six groups: (Group 1) normal control group, (Group 2) benign prostatic hyperplasia model control group, (Group 3) benign prostatic hyperplasia mice treated with finasteride at a dose of 1mg/kg, (Group 4) benign prostatic hyperplasia mice treated with chlorogenic acid at dose levels of 0.8mg/kg (low dose group), (Group 5) benign prostatic hyperplasia mice treated with chlorogenic acid at dose levels of 1.6mg/kg (medium dose group) and (Group 6) benign prostatic hyperplasia mice treated with chlorogenic acid at dose levels of 3.2mg/kg (high dose group). Animals were sacrificed on the scheduled termination, pick out the eyeball to get blood, then prostates were weighed and prostatic index were determined. Then the serum acid phosphatase (ACP), prostatic acid phosphatase (PACP) and typeⅡ5-alpha-reductase (SRD5A2) levels were measured and observed morphological changes of the prostate. Comparing with benign prostatic hyperplasia model group, the high and medium dose of chlorogenic acid could significantly reduce prostate index and levels of acid phosphatase, prostatic acid phosphatase and typeⅡ5-alpha-reductase (P<0.05 or P<0.01). These findings were supported by histopathological observations of prostate tissues. Histopathological examination also indicated that chlorogenic acid treatment at the high and medium doses inhibited testosterone-induced prostatic hyperplasia. The results indicated that chlorogenic acid exhibited restraining effect on benign prostatic hyperplasia model animals, and its mechanism might be related to inhibit typeⅡ5-alpha reductase activity.

Polyphenol composition and antioxidant capacity of Epilobium species

Epilobium species (Onagraceae) are commonly used herbal remedies in traditional, adjuvant therapy of benignus prostate hyperplasia (BPH), however the pharmacological and clinical standardization of commercially available Epilobii herba (willow-herb) remains difficult. Willow-herb products usually consist of mixtures from various species, with different phenoloid content, often only partially identified. The present study reports comprehensive LC-MS/MS investigation on the polyphenol composition of the most common Epilobium species, emphasizing the pharmaceutical importance of a uniform standardization protocol in case of their products. The antioxidant capacity of species was evaluated by a simple spectrophotometric method, using ABTS(+) (2,2'azinobis-(3-ethylbenzthiazoline-6-sulfonic acid)). High ratio of macrocyclic tannins, mainly oenothein B was identified in all Epilobium species examined. Flavonoid composition of Epilobium extracts showed several differences, especially comparing E. angustifolium to other species. Myricetin, quercetin, kaempferol and their various glycosides were dominant in samples, but their combination and ratio were distinctive in all cases. Epilobium extracts showed high radical-scavenger activity, comparable to that of well-known antioxidants, Trolox and ascorbic acid. Among species examined, extract of Epilobium parviflorum possessed the highest antioxidant capacity (EC(50)=1.71+/-0.05 microg/ml).

Inhibitory effect of traditional Chinese medicine Zi-Shen Pill on benign prostatic hyperplasia in rats

In the present study, we investigate the effects of an extract isolated from traditional Chinese medicine Zi-Shen Pill (ZSPE) on benign prostatic hyperplasia (BPH) in rats induced by testosterone after castration. A total of 50 rats were equally divided into five groups: Group 1 served as control (sham-operated group); Group 2 was model group; Group 3 and Group 4 animals were administered with ZSPE at dose levels of 300 mg/kg and 600 mg/kg; Group 5 was served as positive control group and treated with finasteride at a dose of 1 mg/kg. The drugs were administered orally once a day for 28 days consecutively. The prostate weight, prostatic index, and serum dihydrotestosterone (DHT) levels were significantly reduced and the pathological changes in BPH were also by ameliorated ZSPE. Immunohistochemical examination revealed that the expressions of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in prostate were inhibited by ZSPE treatment, whereas the levels of transforming growth factor-beta1 (TGF-beta1) were increased. These results suggest that ZSPE has a definite inhibitory effect on BPH and might be an alternative medicine for treatment of human BPH.

Localized hyperthermia combined with intratumoral dendritic cells induces systemic antitumor immunity

Prostate adenocarcinoma, treated with localized tumor hyperthermia (LTH), can potentially serve as a source of tumor antigen, where dying apoptotic/necrotic cells release tumor peptides slowly over time. In addition, LTH-treated cells can release heat shock proteins that can chaperone antigenic peptides to antigen-presenting cells, such as dendritic cells. We attempted to discern whether sequential LTH and intratumoral dendritic cell and/or systemic granulocyte macrophage colony-stimulating factor (GM-CSF) would activate antitumor immune response in a syngeneic murine model of prostate cancer (RM-1). Palpable RM-1 tumors, grown in the distal appendage of C57BL/6 male mice, were subjected to LTH (43.7 degrees C for 1 h) x 2, separated by 5 days. Following the second LTH treatment, animals received either PBS or dendritic cells (2 x 10(6)) intratumorally (every 3 days for three injections). Separate cohorts also received i.v. injection of recombinant adenovirus-expressing murine GM-CSF (AdGMCSF), 1 day after LTH. Control animals received AdenoLacZ or AdenoGFP. Intratumoral dendritic cell injection induced tumor-specific T-helper cell activity (IFNgamma ELISPOTS) and CTL activity, which was further augmented by AdGMCSF, indicating amplification of tumor-specific TH1 immunity. The combination of LTH, AdGMCSF, and intratumoral dendritic cell injection resulted in significant tumor growth delays when compared with animal cohorts that received LTH alone. These results support an in situ autovaccination strategy where systemic administration of GM-CSF and/or intratumoral injection of autologous dendritic cells, when combined with LTH, could be an effective treatment for local and systemic recurrence of prostate cancer.

TRANSURETHRAL MICROWAVE THERMOTHERAPY FOR BENIGN PROSTATE HYPERPLASIA: SEPARATING TRUTH FROM MARKETING HYPE

PURPOSE

Transurethral microwave thermotherapy (TUMT) is being used with increasing frequency by urologists as a minimally invasive therapy for benign prostatic hyperplasia (BPH). There are various modifications to this technology, with each manufacturer touting safety and efficacy. We review the rationale of TUMT, as well as the historical safety and efficacy of this approach.

MATERIALS AND METHODS

We reviewed the medical literature, including peer reviewed articles and abstracts. In addition, we analyzed promotional material distributed by various manufacturers with respect to scientific accuracy.

RESULTS

TUMT results in consistent improvement in symptoms and peak urinary flow rate. Symptom improvement ranges between 9 and 11 points, compared to a 6-point improvement in sham treated patients, and peak urinary flow rate increases 3 to 5 ml per second. The degree of coagulation necrosis is different among the various TUMT devices. Although coagulation necrosis is believed to be an important proxy for clinical success, there are few data that correlate this factor with the magnitude of either symptomatic or uroflow improvement.

CONCLUSIONS

TUMT is a safe and effective therapy for the treatment of lower urinary tract symptoms secondary to BPH. In addition, there are distinct advantages to each of the devices. However, intense marketing and hyperbole have dominated this segment of the BPH market. Ultimately, the most effective TUMT device can only be determined by direct comparison studies.

Gadolinium-enhanced MRI in the evaluation of minimally invasive treatments of the prostate: correlation with histopathologic findings

OBJECTIVES

To explore the use of magnetic resonance imaging (MRI) with gadolinium enhancement as a noninvasive method to image the extent of ablation after minimally invasive treatment. Minimally invasive methods for ablating prostatic tissue have emerged as a viable option in the treatment of prostate disease. As these devices enter the mainstream of patient care, imaging methods that verify the exact location, extent, and pattern of the ablation are needed.

METHODS

Nineteen patients with prostate cancer were evaluated. All received some type of minimally invasive treatment, post-treatment gadolinium-enhanced MRI sequences, and radical retropubic prostatectomy for histopathologic evaluation. Visual comparisons of gadolinium defects and areas of coagulation necrosis as seen on histopathologic evaluation were made by us. Volumetric and two-dimensional area measurements of the ablation lesions were also compared for correlation between the MRI and histopathologic results.

RESULTS

Gadolinium-enhanced MRI could be matched to histopathologic findings by visual comparison in 17 of the 19 cases. Surgically distorted histopathologic specimens and a small periurethral lesion caused 2 patients to have MRI and histopathologic results that could not be matched. Complete volumetric measurements were available for 16 of the 19 patients and correlated strongly (r = 0.924). The two-dimensional area data for all patients also showed significant correlation (r = 0.886).

CONCLUSIONS

Correlation with histopathologic findings showed gadolinium-enhanced MRI to be useful for determining the location, pattern, and extent of necrosis caused within the prostate by minimally invasive techniques. Gadolinium-enhanced MRI gives the urologist a useful tool to evaluate the effectiveness of new minimally invasive therapies.

Conductive Heat: Hot Water-Induced Thermotherapy for Ablation of Prostatic Tissue

Water-Induced Thermotherapy (WIT trade mark ) was developed to treat lower urinary tract symptoms (LUTS) and to reduce bladder outlet obstruction (BOO) secondary to benign prostatic hyperplasia (BPH). The principle is to produce heat-induced coagulative necrosis and secondary ablation of the obstructing hyperplastic tissue. The source of thermal energy is heated water circulated in a proprietary closed-loop system, which includes a specially designed catheter. To date, few papers on WIT have been published in peer-reviewed journals. The initial studies focused on feasibility and safety, while later ones were designed to demonstrate tissue and pathologic effects. In a prospective international study, 125 patients were enrolled at eight study centers and evaluated both short term (3, 6, and 12 months) and long term (24 and 36 months). The duration of indwelling catheterization was as follows: 45.5% of patients were catheter free after 1 week (the minimum required by the protocol), 30.5% after 2 weeks, and the remaining 24.0% after 3 to 5 weeks. No patients were asked to do intermittent catheterization. Adverse events were those commonly seen after manipulation of the lower urinary tract. International Prostate Symptom Score, Quality of Life score, peak uroflow rate (Q(max)), and postvoiding residual urine volume had improved significantly at 12, 24, and 36 months. Data reported in a more recent abstract indicate that favorable effects on symptoms and voiding parameters continue to at least 36 months. The WIT procedure was also associated with statistically significant post-treatment prostate shrinkage (median 3.2 cc) at 12 months compared with baseline. The reported failure rate and the rate of subsequent transurethral resection was 5.6% after 12 months, 9.6% after 24 months, and 11.2% after 36 months. According to the literature, WIT is a useful technique to treat BPH-related LUTS and BOO, with a success rate on an intention-to-treat basis of approximately 90% after 12 months and 75% after 24 months.

Fast liquid ablation system for prostatic hyperplasia: a new minimally invasive thermal treatment

PURPOSE

We determined patient tolerance and the sequence of histopathological changes of thermal injury and healing of the prostate after treatment with a novel, rapid, high temperature, liquid filled, flexible balloon thermotherapy system.

MATERIALS AND METHODS

A total of 17 patients scheduled for prostatic surgery received preoperative high temperature water balloon thermotherapy. In 13 patients intraprostatic, urethral and rectal temperatures were continuously monitored and determined using stereotactic thermal mapping with the patient under spinal anesthesia. The remaining 4 patients had lidocaine gel as the only method of pain control. Patient discomfort was recorded at all times during the procedure. After treatment a prostatic stent was left in place until surgery or spontaneous voiding. Serial sections of the resected prostates were evaluated pathologically with mapping.

RESULTS

Treatment was well tolerated by all patients. Prostates were enucleated (in 12 patients) or entirely removed (in 5) at a mean of 35 days (range 15 to 173) after thermotherapy. The predominant pathological findings in the early phase were uniform periurethral hemorrhagic necrosis, extensive urothelial denudation and varying degrees of inflammation. The mean radial depth of necrosis (from the urethra to the viable tissue border) was 0.9 cm (range 0.6 to 1.5) involving a mean of 16% of the prostatic adenoma (range 7.8% to 32%). In the late (resolution) phase necrotic tissue had been replaced by scar tissue (fibrosis and hyalinization) with a mean radial depth of 0.13 cm (range 0.01 to 0.24), and the urothelium had largely regrown along the urethra.

CONCLUSIONS

The fast liquid ablation system for hyperplasia is a new minimally invasive treatment that induces considerable thermal injury to the prostate with uniform necrosis and subsequent sloughing of dead tissue, allowing enlargement of the urethral lumen.

Histological changes of minimally invasive procedures for the treatment of benign prostatic hyperplasia and prostate cancer: clinical implications

PURPOSE

Benign prostatic hyperplasia (BPH) is near universal in aging men, creating tremendous costs in morbidity and surgical treatment. In the last decade numerous nonsurgical minimally invasive methods have emerged for ablation of prostatic tissue.

MATERIALS AND METHODS

We reviewed the recently published English language literature on minimally invasive techniques for treating BPH and cancer with an emphasis on histopathological findings.

RESULTS

We compared the spectrum of contemporary minimally invasive treatments for BPH and cancer, with an emphasis on histopathological results. Clinical results were summarized briefly for each treatment method. These procedures ablate tissue by thermal, cryogenic, chemical or enzymatic injury. The 5-year results for some techniques were promising, although long-term durability is still uncertain, and other methods were in preclinical or early clinical stages. Invariably the treated tissue was devitalized with a thin border of granulation tissue and fibrosis. These procedures have applications for BPH and prostate cancer, although some studies are limited to only 1 disease.

CONCLUSIONS

Minimally invasive procedures show promise of a durable replacement for surgical resection.

Treatment of benign prostatic hyperplasia with water-induced thermotherapy: experience of a single institution

PURPOSE

To evaluate the efficacy of and tolerance for water-induced thermotherapy (WIT).

PATIENTS AND METHODS

Between June 1998 and December 1999, 50 patients were treated with WIT protocol. The patients were divided in two groups according to the achieved treatment temperature and the volume of the inflated treatment balloon. In Group 1, the treatment temperature was set at 60 degrees C, and the treatment balloon was inflated to 50F. In Group II, 29 patients were treated with a temperature of 62 degrees C, and the treatment balloon was inflated to a maximum of 60F.

RESULTS

In Group I, the catheter was permanently removed in eight of the nine patients who had previously had permanent indwelling bladder catheters (88.8%). The average Qmax was 11.5 mL/sec; the quality of life (QoL) index was 1.3, and the International Prostate Symptom Score (IPSS) was 6.2. The remaining five patients were not catheter dependent prior to WIT. Three of these patients (60%) demonstrated Qmax improvements from 11.7 to 17.1 mL/sec. In Group II, 11 of the 15 patients (73.3%) who had been catheter dependent resumed spontaneous micturition with a Qmax of 10.7 mL/sec and an IPSS of 8.5.

CONCLUSION

Water-induced thermotherapy can be performed easily on an outpatient basis under local anesthesia. It is well tolerated by most patients, and the early results are encouraging.

Minimally invasive therapies for benign prostatic hyperplasia

Currently, 3 categories of treatment are available for men with benign prostatic hyperplasia (BPH): (1) medicine, such as alpha-blockers and finasteride; (2) minimally invasive treatment, such as transurethral microwave thermotherapy and interstitial ablation using either radiofrequency or laser; and (3) surgical therapy. The 1990s have seen an explosion of transurethral technology to treat symptoms caused by bladder outlet obstruction secondary to BPH. Unlike surgical debulking procedures, the minimally invasive therapies attempt to treat patients without general or regional anesthesia, and even ambulatory procedures are performed in the office. Because of the demographics of patients with BPH, it is hoped that these minimally invasive options will relieve symptoms without any surgical complications and the side effects and compliance issues associated with medical therapy. It is important that urologists have a clear understanding of the clinical usefulness of these devices, so that the overall role of such treatment may be determined by science rather than marketing. Clinically, the degree of symptom score, peak flow, and quality-of-life improvement seen with all the minimally invasive techniques are similar. The techniques may differ in their ability to reach the maximum number of responders and achieve an acceptable duration of response, and the need for analgesia/sedation associated with each technique. This study will define the minimally invasive therapies and present the differences in catheter design and technique. The pathologic basis for these therapeutic options and the advantages and disadvantages of each will be discussed. Urologists must decide which therapy can be used in their office practice. The maximum numbers of responders and enhanced durability of the treatment can be achieved based on realistic expectations, proper selection of patients, and complete information on the potential of these devices.

Transurethral hot water balloon thermoablation

The inclusion of a determinate technique among the "minimally invasive treatments" of the symptoms due to benign prostatic hyperplasia is a long and careful process. The technique has to be more patient-friendly than conventional techniques, but also needs to be time-tested against older methods. Most of these minimally invasive treatments are based upon distinct types of thermoablation; the method discussed here, hot water balloon thermoablation, is based on the heat conductive properties of the prostatic tissue.

Minimally invasive procedures as an alternative to medical management for lower urinary tract symptoms of benign prostatic hyperplasia

Data are reviewed relating to the safety and efficacy of minimally invasive transurethral microwave thermotherapy and medical management in patients with lower urinary tract symptoms of benign prostatic hyperplasia. Recent evidence is summarized indicating more pronounced long-term beneficial effects of microwave treatment. alpha-Blockade, however, offers the advantage of more rapid action than microwave treatment. Neoadjuvant and adjuvant alpha-blocker therapy can accelerate symptom and flow rate improvement in patients receiving microwave treatment. Compared with medical management, microwave treatment possesses greater versatility, allowing patients with severe baseline symptoms and small prostate sizes to be treated with a high probability of success.