Pilot study of transperineal injection of dehydrated ethanol in the treatment of prostatic obstruction

[Botulinum toxin in male lower urinary tract symptoms (LUTS): What can we expect?]

During the last two decades botulinum toxin has also conquered urology. Botulinum toxin reduces the contractility and sensitivity of the detrusor muscle and relieves pain. It is therefore a promising drug whose use in men also appears promising. The following article highlights the practical relevance of botulinum toxin for male lower urinary tract symptoms (LUTS). But first of all, a distinction must be made between use in male LUTS due to benign prostate syndrome (BPS) and use in cases of overactive bladder (OAB) alone. A differentiated diagnosis and treatment of male LUTS is therefore essential.

Time-dependent image changes after ethanol injection into the pancreas: an experimental study using a porcine model

Background

Ethanol, a commonly available agent, has been used to successfully ablate cystic and solid lesions in the pancreas. The aim of this study is to investigate the effects of an ethanol injection into the porcine pancreas and observe the time-dependent image changes in the pancreatic parenchyma.

Methods

Pure ethanol was injected into the pancreatic tail using a 25-gauge EUS needle with direct ultrasound guidance under celiotomy: 1 mL and 2 mL were injected, respectively. The abdomen was closed after the injection. MRI was performed before the procedure, immediately after, and on postoperative day (POD) seven. Blood samples were taken before the procedure and on PODs one, three, five, and seven. The pigs were euthanised on POD seven.

Results

Immediately after the injection, linear high signal areas in the pancreatic tail on T2 and rounded speckled high signal areas on DWI images were detected in both animals, measuring 35 × 32 mm in the 1 mL injected pig and 42 × 38mm in the 2 mL injected pig. After POD seven, rounded high signal areas were noted on T2 images, measuring 22 × 18 mm and 36 × 28 mm respectively. On POD one, the 1 mL injected animal had a 53% elevation in serum amylase while the 2 mL injected animal had a 66% elevation. Histologically, cystic and necrotic changes in the parenchyma were observed, measuring 23 × 22 mm and 40 × 35 mm respectively.

Conclusions

Our results, which are limited to normal pancreas, suggested that a 1 mL injection caused localised changes within the pancreas while a 2 mL injection induced more widespread changes beyond the pancreas. The effective area of ethanol was widespread immediately after injection, and then the area was reduced with cystic and necrosis changes.

Endoscopic ultrasound-guided ethanol injection in the pancreas in a porcine model: a preliminary study

BACKGROUND AND AIM

Despite aggressive multimodal treatments, survival rates for patients with pancreatic cancer remain disappointing. Local progression is problematic, and minimally invasive procedures allowing locoregional control are needed. In this study, we attempted endoscopic ultrasound (EUS)-guided injection of ethanol into the pancreas.

METHODS

Under EUS guidance, pure ethanol (2 mL) was injected into normal tissue of the pancreatic body in two anesthetized domestic pigs. Serum concentrations of amylase, aspartame aminotransferase, alanine aminotransferase, alkaline phosphatase, and lactate dehydrogenase were measured before treatment and at 2 h, 48 h and 2 weeks after injection. Body weight and clinical signs were also observed. After the animals were euthanized, the pancreases were analyzed histologically.

RESULTS

EUS imaging allows real-time surveillance of the injection procedure. Mild diarrhea was noted in one animal, but no other adverse effects were observed. No marked changes in laboratory tests were noted. Histologically, parenchymal necrosis extending over a wide area was seen without severe inflammation.

CONCLUSION

EUS-guided ethanol injection in the pancreas seems to be technically simple. More detailed assessments of the safety and dose-effect relationship issues associated with this procedure are required.

Effects of direct injection of dehydrated ethanol on PC3 human prostate cancer cells in nude mice: Preliminary study

OBJECTIVES

The effect of direct local injection of dehydrated ethanol on hormone-independent prostatic carcinoma cells (PC3 cells) implanted in nude mice was investigated.

METHODS

PC3 tumors were implanted subcutaneously into 30 nude mice. Three weeks later, dehydrated ethanol was injected directly into the tumors. Twenty-three animals received an injection of ethanol at a volume of 40 microL, 80 microL, or 160 microL, and were divided into a low-dose group (n = 11) and a high-dose group (n = 12) on the basis of the ethanol/tumor volume ratio (<30% versus> or =30%). The control group (n = 7) was injected with 40 microL of physiological saline. The tumor volume before treatment was 324.9 +/- 110.9 mm(3) and was assessed as well as 1 day, 4 days, 1 week, 2 weeks, and 3 weeks after injection. Then the changes of tumor volume were compared between the two ethanol groups (low-dose group and high-dose group) and the control group. Histological examination was performed for up to 3 weeks after injection.

RESULTS

Assessment of tumor volume showed that the ethanol/tumor volume ratio was 16.1 +/- 5.3% in the low-dose group (n = 5) and 51.8 +/- 20.3% in the high-dose group (n = 6). Tumor growth was significantly inhibited after 1 and 2 weeks in the ethanol groups compared with the control group (n = 3). After 3 weeks, there was a tendency for tumor regrowth in the low-dose group, but growth inhibition was maintained in the high-dose group. Histological examination showed tumor degeneration and necrosis with feeding vessel obstruction in the acute phase.

CONCLUSIONS

Local injection of dehydrated ethanol regressed tumors of prostatic carcinoma cells in nude mice, with the degeneration of tumor cells and occlusion of feeding vessels.

Sustained beneficial effects of intraprostatic botulinum toxin type A on lower urinary tract symptoms and quality of life in men with benign prostatic hyperplasia

OBJECTIVE

To present a comprehensive experience with intraprostatic botulinum toxin-type A (BoNT-A) injection in men with symptomatic benign prostatic hyperplasia (BPH) and to assess the efficacy on lower urinary tract symptoms (LUTS) and quality of life (QoL).

PATIENTS AND METHODS

In all, 41 men (mean age 69.1 years, sd 7.1 ) with an International Prostate Symptom Score of > or = 8, peak flow rate of < 12 mL/s, and who were refractory to medical treatment were injected with BoNT-A (Botox, Allergan, Inc., CA, USA) at 100 U (21 men, for prostate volume < 30 mL) or 200 U (20, for prostate volume > 30 mL) into the prostate transperineally under transrectal ultrasonography guidance. Study exclusion criteria were confirmed or suspected malignancy, previous pelvic surgery or trauma and previous invasive treatment for BPH. The clinical effects were evaluated at baseline and at 1, 3 and 6 months after treatment.

RESULTS

There were no significant local or systemic side-effects in any men. LUTS and QoL indices improved by > 30% in 31 of the 41 men (76%), and four of five men with urinary retention for > 1 month could void spontaneously at 1 week to 1 month after the BoNT-A injection. In 12 of 41 men (29%) there was no change in prostate volume, yet seven of these men still had a > 30% improvement in maximum flow rate, LUTS and QoL. The efficacy was sustained at 12 months.

CONCLUSION

BoNT-A injected into the prostate is safe and effective for men with symptomatic BPH. The mechanisms of relief of symptoms might not depend totally on the volume shrinkage; the inhibitory effect on the smooth muscle tone and aberrant sensory function might also be important.

Transurethral ethanol injection for prostatic obstruction: an excellent treatment strategy for persistent urinary retention

OBJECTIVES

To evaluate the efficacy of transurethral ethanol injection into the prostate (TUEIP) for patients with persistent urinary retention resulting from benign prostatic hyperplasia or advanced prostate cancer.

METHODS

Twenty-one Japanese men (elderly or at high risk anesthesiologically) who had developed persistent urinary retention because of benign prostatic hyperplasia or advanced prostate cancer were treated with TUEIP from January 2001 to January 2005. Patient age and preoperative prostate volume was 64 to 92 years (median 84) and 24.1 to 125 cm3 (mean 57.6), respectively. Under sacral or lumbar anesthesia, 6 to 14 mL (mean 10.6) of dehydrated ethanol (mean ratio for prostate volume 22.7%) was injected into the prostate under endoscopic guidance, followed by placement of an indwelling catheter.

RESULTS

Of the 16 patients with benign prostatic hyperplasia and 5 with advanced prostate cancer, 14 (87.5%) and 3 (60%), respectively, were able to void spontaneously after catheter removal. The catheter had been left in place for 7 to 37 days (mean 12.4) after surgery. No additional treatment was required during the 2 to 24 months (mean 16) of follow-up. The postoperative residual urine volume of these 17 patients was 20 to 150 mL (mean 60) and their mean prostate volume had decreased from 52.7 to 37.9 cm3 (28.1% reduction) at 6 months postoperatively (P <0.001). No major complication was experienced.

CONCLUSIONS

In patients with persistent urinary retention due to prostatic obstruction without severe complications, TUEIP removes the need for catheterization and allows spontaneous voiding. TUEIP may be an alternative to transurethral resection of the prostate for high-risk or elderly patients who cannot tolerate surgery.

Pathological effects of alcohol septal ablation for hypertrophic obstructive cardiomyopathy

BACKGROUND

The pathological effects and the mechanisms of action of intracoronary administration of ethanol for alcohol septal ablation (ASA) for the management of hypertrophic obstructive cardiomyopathy (HOCM) are unknown.

METHODS

We examined surgical specimens and, in one case, autopsy specimens from four patients who underwent surgical septal myectomy 2 days to 14 months after unsuccessful ASA.

RESULTS

Pathological examination early after ASA showed coagulative necrosis of both the myocardium and the septal perforator arteries. Affected arteries were distended and occluded by necrotic intraluminal debris, without platelet-fibrin thrombi. Late after unsuccessful ASA, excised septal tissue was heterogeneous, containing a region of dense scar, and adjacent tissue containing viable myocytes and interspersed scar.

CONCLUSIONS

Intracoronary administration of ethanol in patients with HOCM causes acute myocardial infarction with vascular necrosis. The coagulative necrosis of the arteries, their distension by necrotic debris and the absence of platelet-fibrin thrombi distinguish ethanol-induced infarction from that caused by atherosclerotic coronary artery disease. The direct vascular toxicity of ethanol may be an important aspect of the mechanism of successful ASA.

Intraprostatic injection of botulinum toxin type-A relieves bladder outlet obstruction in human and induces prostate apoptosis in dogs

BACKGROUND

With the increasing interest with botulinum toxin--A (BTX-A) application in the lower urinary tract, we investigated the BTX-A effects on the canine prostate and also in men with bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH).

METHODS

Transperineal injection into the prostate using transrectal ultrasound (TRUS) was performed throughout the study. Saline with or without 100 U of BTX-A was injected into mongrel dogs prostate. One or 3 months later, the prostate was harvested for morphologic and apoptotic study. In addition, eight BPH patients refractory to alpha-blockers were treated with ultrasound guided intraprostatic injection of 200 U of BTX-A.

RESULTS

In the BTX-A treated dogs, atrophy and diffuse apoptosis was observed with H&E stain and TUNEL stain at 1 and 3 months. Clinically, the mean prostate volume, symptom score, and quality of life index were significantly reduced by 18.8%, 73.1%, and 61.5% respectively. Maximal flow rate significantly increased by 72.0%.

CONCLUSION

Intraprostatic BTX-A injection induces prostate apotosis in dogs and relieves BOO in humans. It is therefore a promising alternative treatment for refractory BOO due to BPH.

Botulinum toxin type A improves benign prostatic hyperplasia symptoms in patients with small prostates

OBJECTIVES

To expand the clinical use of botulinum toxin A (BTX-A) in treating patients with small prostates and symptomatic benign prostatic hyperplasia (BPH). BTX-A injection into the prostate in patients with voiding dysfunction and large prostates has been reported.

METHODS

Sixteen men with symptomatic BPH, a prostate volume less than 30 cm3, peak flow rate less than 12 mL/s, and with refractory disease after at least 1 month of alpha-blocker treatment received BTX-A 100 U injection into the prostate transperineally under transrectal ultrasound guidance. The clinical effects were evaluated at baseline and after treatment.

RESULTS

No significant local or systemic side effects were observed in any of the patients. All patients reported subjective improvement starting at approximately 1 week and achieved a maximal effect after 1 month that was maintained at 3 and 6 months. At 6 to 12 months (mean 10) of follow-up, no patient had symptom recurrence. The mean prostate volume, symptom score, and quality-of-life index were significantly reduced by 13.3% (from 19.6 +/- 1.2 to 17.0 +/- 1.1 cm3), 52.6% (from 18.8 +/- 1.6 to 8.9 +/- 1.9), and 44.7% (from 3.8 +/- 0.3 to 2.1 +/- 0.3), respectively. The maximal flow rate increased significantly by 39.8% (from 7.3 +/- 0.7 to 11.8 +/- 0.8 mL/s). In 2 patients who underwent biopsy 1 month after BTX-A injection, terminal deoxynucleotidyl-mediated deoxyuridine triphosphate nick end labeling staining demonstrated an increase in apoptotic activity, not only in the glandular component, but also in the stromal component of the prostatic tissue.

CONCLUSIONS

BTX-A injected into the prostate is a promising treatment for patients with small prostates and symptomatic BPH.

Intravesical calculus secondary to ethanol gel injection into the prostate

A 78-year-old man with coagulopathy and lower urinary tract symptoms secondary to benign prostatic hyperplasia underwent transurethral prostate ethanol gel injection. Six months after the injection, the patient presented with irritative symptoms and hematuria. Ultrasonography revealed a 5-cm intravesical calculus. Cystolitholapaxy was unsuccessful, and the patient underwent cystolithotomy with retrieval of a large, soft, round, brownish mass. Histologic examination of the mass demonstrated prostatic hyperplastic glandular stroma with extensive coagulate necrosis and peripheral calcification. To our knowledge, this is the first report of a calculus formed by prostatic tissue slosh after ethanol injection.

TRANSURETHRAL ETHANOL INJECTION THERAPY FOR PROSTATIC HYPERPLASIA: 3-YEAR RESULTS

PURPOSE

We assessed the medium-term (3-year) efficacy of transurethral ethanol injection therapy of the prostate (EIP) for benign prostatic hyperplasia.

MATERIALS AND METHODS

A total of 34 patients were followed for a median of 4.3 years after EIP. Mean age was 68.1 years and mean baseline prostate volume was 49.3 ml. With the patient under combined sacral and urethral anesthesia, dehydrated ethanol was injected into the prostate with endoscopic guidance. A urethral catheter was inserted postoperatively.

RESULTS

Mean total ethanol dose was 6.4 ml and a catheter was required for a mean of 7.6 days postoperatively. Mean International Prostate Symptom Score was 21.8 points before EIP (in 34 patients), and decreased to 13.1 points after 3 years (in 17, p <0.01). Mean quality of life index decreased from 5.0 points before EIP to 2.8 points after 3 years (p <0.001). Mean peak urine flow rate was 8.3 ml per second before EIP and increased to 12.7 ml per second after 3 years (p <0.01). Mean residual urine volume decreased from 93 ml before EIP to 28 ml after 3 years (p <0.01). Mean prostate volume decreased from 49.3 ml before EIP to 45.7 ml after 1 year (p <0.001), but increased to 51.4 ml after 3 years. No major complications were experienced. By 3 years after surgery 59.0% of patients had not required further treatment.

CONCLUSIONS

Transurethral EIP caused minimal complications while maintaining improvement of the prostate symptom score and an increased peak urine flow after 3 years.

PROSTATIC TISSUE ABLATION BY INJECTION: A LITERATURE REVIEW

PURPOSE

Most men 50 to 80 years old will have development of some degree of benign prostatic hyperplasia (BPH). Many who experience lower urinary tract symptoms (LUTS) will be treated medically. However, significant numbers will have more severe and progressive disease requiring surgery. Transurethral resection of the prostate is the current gold standard of treatment for BPH. Minimally invasive therapies for symptomatic BPH emerge and fade continuously. However, intraprostatic injection for BPH has been used for more than 100 years and may be on the verge of a rebirth. The goal of this review is to familiarize the reader with the origins and history of intraprostatic injection, and its evolution using transperineal, transrectal and transurethral routes with multiple injectants. Initially used to treat urinary retention in men with BPH, its primary indication is now for LUTS.

MATERIALS AND METHODS

We performed a structured MEDLINE review of the literature on intraprostatic injections from 1966 to 2003, augmented with relevant articles from select journals and documents dating to 1832.

RESULTS

In patients with BPH transperineal and transurethral injections have the most systematic evaluation. Most injectants will cause localized prostatic necrosis and gland volume reduction with varying degrees of LUTS relief. Anhydrous ethanol is the most widely studied injectable to date. There are advantages and disadvantages associated with each route of injection.

CONCLUSIONS

Examined for more than a century, the potential for using injectables for prostatic tissue ablation remains significant. More systematic laboratory research and clinical trials, currently ongoing, need to be completed.