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Evaluative care guideline compliance is associated with provision of benign prostatic hyperplasia surgery. Urology 2012; 80:84-9. [PMID: 22608799 DOI: 10.1016/j.urology.2012.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 03/01/2012] [Accepted: 03/13/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the impact of evaluative care guideline compliance on surgical intervention for benign prostatic hyperplasia (BPH). METHODS From Medicare claims data, we developed a cohort of men new to a urologist with a diagnosis of BPH. We determined urologists' compliance with guideline recommended care (3 months) and their time- and geography-standardized average monthly Medicare expenditures (1 year). At the level of the urologist, we assessed the impact of these measures on the use of surgical therapy within 1 year of the new patient visit. RESULTS Of 10 248 patients in the cohort, 675 received surgical intervention (6.7%). Guideline compliance (2% received surgery in highest quintile; 11% lowest quintile) was associated with surgical intervention. The results were robust to adjustment for patient and surgeon factors (Guideline Compliance, odds ratio = 0.09; 95% confidence interval = 0.06-0.15, highest to lowest adherence). CONCLUSION Urologists who tend to follow the AUA best practice guidelines for BPH evaluation perform surgical interventions on their BPH patients less frequently than urologists who do not follow these guidelines.
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Ferakis N, Skolarikos A, Staios D, Liakouras C, Alivizatos G. Treatment Characteristics and Inherent Prostatic Features Do Not Predict Patient Outcome after High-Energy Transurethral Thermotherapy: A Prospective Study of ProstaLund Feedback Treatment™. J Endourol 2006; 20:1075-81. [PMID: 17206906 DOI: 10.1089/end.2006.20.1075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To determine whether treatment characteristics, intrinsic prostatic factors, and clinical parameters predict the outcome in patients treated with high-energy transurethral microwave thermotherapy (HE-TUMT). PATIENTS AND METHODS A series of 48 consecutive patients, 28 with an indwelling catheter, underwent ProstaLund Feedback Treatment (PLFT). The 12-month International Prostate Symptom Score response rate (IPSS < or = 7 or > or =50% improvement), peak flow rate response rate (Q(max) > or = 15 mL/sec or > or =50% improvement), and bladder outflow obstruction index response rate (BOOI <40) were correlated with treatment characteristics such as duration, average intraprostatic temperature, time with therapeutic intraprostatic temperatures (>45 degrees C), average intraprostatic blood flow, consumed energy, and recorded prostate mass destruction. Baseline parameters such as age, serum prostate specific antigen concentration, prostate volume, and pretreatment IPSS, quality of life (QOL), Q(max), postvoiding residual urine volume (PVR), and BOOI were included in the logistic regression analysis. RESULTS Treatment characteristics did not discriminate responders and nonresponders to HE-TUMT. For the patients without a catheter, the IPSS response (75%) was predicted by higher pretreatment IPSS (P = 0.041; relative risk [RR] = 3.4) and higher pretreatment PVR (P = 0.026; RR = 1.1). The Q(max) response (85%) was predicted by higher grades of pretreatment obstruction (P = 0.009; RR = 1.02). The BOOI response (60%) was not related to any of the factors tested. For the patients with a catheter, no outcome predictors could be identified. CONCLUSIONS According to our results, the intraprostatic temperature, the duration of intraprostatic temperatures in the therapeutic range, and the pattern of blood flow did not predict HE-TUMT outcome. Treatment duration, consumed energy, and the magnitude of tissue necrosis did not translate into clinical efficacy. Clinical parameters were important predictors of outcome in patients not in retention.
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Affiliation(s)
- N Ferakis
- 2nd Department of Urology, School of Medicine, University of Athens, Sismanoglio General Hospital, Athens, Greece
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Vesely S, Knutson T, Damber JE, Dicuio M, Dahlstrand C. TURP and low-energy TUMT treatment in men with LUTS suggestive of bladder outlet obstruction selected by means of pressure-flow studies: 8-year follow-up. Neurourol Urodyn 2006; 25:770-5. [PMID: 17016845 DOI: 10.1002/nau.20233] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
AIMS To evaluate the long-term outcome of transurethral resection of the prostate (TURP) and transurethral microwave thermotherapy (TUMT) in men with symptomatic benign prostatic hyperplasia (BPH), when allocation to the treatment-group was based on urodynamic diagnosis of bladder outlet obstruction (BOO). METHODS A total of 231 elderly men with symptomatic BPH were treated either by TURP or by low-energy TUMT. A pressure-flow study was performed to detect the obstruction and to help in the selection of the two treatments. The patients were examined at baseline then checked again after 2 and 8 years. RESULTS At 2 years of follow-up there was a significant improvement for both IPSS and QoL (P < 0.0001) in both groups of treatment. This was accompanied by a significant improvement (P < 0.0001) in the maximum flow rate from 10.0 (5.8) to 16.4 (7.6) in the TURP group and from 12.1 (5.2) to 14.9 (5.7) in the TUMT group. These findings persisted at 8 years, they were, however, more pronounced after TURP. The overall retreatment rate reached a value of 11% in the TURP group and 27% in the TUMT group, respectively. At the follow-up, 95% of the patients who underwent TURP and 70% of the patients treated by TUMT claimed to be satisfied with that choice. CONCLUSIONS With durable symptomatic improvement and lowest retreatment rate, TURP still presents a standard treatment option for patients with severe BOO. Low-energy TUMT has sufficiently relieved patients' symptoms and can be offered to less obstructed patients as an alternative.
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Affiliation(s)
- Stepan Vesely
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden.
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Erichsen C. TUMT 2.0: results three months and three years after treatment. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 2003; 37:31-4. [PMID: 12745740 DOI: 10.1080/00365590310008659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine the durability of the results following low-power transurethral microwave thermotherapy (TUMT). MATERIAL AND METHODS 28 patients 55 to 83 years of age with lower urinary tract symptoms (LUTS) and marginal/moderate infravesical obstruction and 4 patients with LUTS, peak urinary flow (Qmax) less than than 15 ml/sec and prostate volume below 40 ml. We used a Prostatron version 2.0. RESULTS transurethral resection of the prostate (TURP) was done shortly after treatment in one patient with acute obstruction caused by necrotic tissue. Three months after treatment 15 patients reported that they were cured from LUTS and 10 experienced improvement of symptoms. A significant reduction of the symptom scores was seen among the 31 patients not operated while Qmax was unchanged. Three years after treatment two patients were still cured from LUTS, 9 hadsome reduction of symptoms, and TURP had been done in further three patients. Symptom scores among the 24 patients still in the study were significantly lower than the baseline values but also significantly higher than the symptom scores three months after treatment. Residual urine was reduced while no changes were seen in Qmax. CONCLUSION TUMT done by Prostatron version 2.0 causes mainly a reduction of symptoms. Most of the effect disappears after a few years.
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Seitz C, Djavan B, Marberger M. Morphological and biological predictors for treatment outcome of transurethral microwave thermotherapy. Curr Opin Urol 2002; 12:25-32. [PMID: 11753130 DOI: 10.1097/00042307-200201000-00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The proliferation of prostatic tissue as a result of ageing typically leads to prostatic enlargement, which often causes obstruction of urine outflow from the bladder, clinically lower urinary tract symptoms, detrusor instability, incomplete bladder emptying, urinary infection, and finally acute urinary retention. The first approach to therapy depending on the severity of the symptoms is usually medical management (phytotherapy, alpha-blockers, 5 alpha-reductase inhibitors) before surgical procedures are performed. The reference standard for treatment of benign prostatic hyperplasia is transurethral resection of the prostate, although the introduction of minimally invasive alternatives such as transurethral microwave thermotherapy has led to a new era in surgical management. Suitable patients must be selected carefully on the basis of individual parameters that predict a favourable result.
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Affiliation(s)
- Christian Seitz
- Department of Urology, University of Vienna, Vienna, Austria
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Abstract
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.
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Affiliation(s)
- M L Blute
- Department of Urology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Terada N, Aoki Y, Ichioka K, Matsuta Y, Okubo K, Yoshimura K, Arai Y. Microwave thermotherapy for benign prostatic hyperplasia with the Dornier Urowave: response durability and variables potentially predicting response. Urology 2001; 57:701-5; discussion 705-6. [PMID: 11306384 DOI: 10.1016/s0090-4295(00)01118-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To evaluate the clinical efficacy and durability of transurethral microwave thermotherapy (TUMT) in the treatment of benign prostatic hyperplasia. The clinical variables useful in predicting outcome were identified. METHODS From October 1996 to March 2000, 58 patients with symptomatic benign prostatic hyperplasia were treated with TUMT using the Urowave device. Treatment outcome was evaluated by the International Prostate Symptom Score (IPSS), quality-of-life assessment score, and urodynamic investigation. The patients were divided into those having a good and poor response on the basis of the degree of IPSS decrease at 3 months. RESULTS The mean IPSS significantly decreased from 19.2 at baseline to 13.3 at 3 months (P <0.0001). The mean quality-of-life score changed from 4.6 at baseline to 2.9 at 3 months (P <0.0001). No statistically significant differences in peak flow rate, postvoid residual volume, Schäfer's obstruction scale, or detrusor pressure at peak flow were noted before or after TUMT. The pretreatment IPSS of the good response group was significantly higher than that of the poor response group (P=0.017). A more significant difference was obtained for the obstructive score (P = 0.002), and no difference was observed in the irritative score (P = 0.631). The Schäfer grading scale score of the good response group was significantly smaller than that of the poor response group (P = 0.047). CONCLUSIONS TUMT with the Urowave was effective in eliminating symptoms associated with benign prostatic hyperplasia, but did not markedly improve the objective voiding parameters. Patients with urodynamically less obstructive symptoms but subjectively more obstructive symptoms are therefore probably good candidates for TUMT.
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Affiliation(s)
- N Terada
- Department of Urology, Kurashiki Central Hospital, Kurashiki, Japan
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Abstract
The application of heat with curative aim is an old and very well-known principle in medicine. A review of the history of heat use in the treatment of prostatic disease is presented. The article is based on bibliographic research (MEDLINE Search and PubMed) and focuses on treatment of benign prostatic hyperplasia (BPH) since the first clinical documentation of transrectal hyperthermia for this condition. Then, in a chronological sequence, not only the evolution toward thermotherapy but also enhancements of the latest techniques are presented. The new advances in the field of patient selection, indications, and outcome predictors, as well as new trends in treatment are briefly considered.
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Affiliation(s)
- M P Laguna
- Urology Department, St. Radboud Medical Center, Nijmegen, The Netherlands.
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Lynch WJ, Graber SF. Transurethral microwave thermotherapy: symptom relief v urodynamic changes. J Endourol 2000; 14:657-60. [PMID: 11083408 DOI: 10.1089/end.2000.14.657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Transurethral microwave thermotherapy (TUMT), whether in its low- or high-energy form, seems to reduce the symptoms of benign prostatic hyperplasia, with low-energy treatment resulting in less improvement than high-energy treatment. Low-energy TUMT has a minimal effect on bladder outlet obstruction, as judged by urodynamic findings, and may not be suitable to treat those patients with significant obstruction. High-energy TUMT does seem to relieve obstruction significantly, although it is not as effective as TURP. Urodynamic studies may provide the answer as to which therapy to offer the patient.
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Affiliation(s)
- W J Lynch
- Department of Urology, The St George Hospital, Sydney, NSW, Australia
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Abstract
Although some authors have proposed that the favorable impact of transurethral microwave thermotherapy (TUMT) for benign prostatic hyperplasia has only a placebo effect, this idea is inconsistent with the findings of a number of sham-controlled clinical trials. Histologic and immunohistochemical studies have shown that the nerve fibers in the periurethral tissue are damaged or ablated by TUMT, and it appears that the heat affects the innervation of the smooth muscle cells. Among the nerves damaged are the sensory neurons of the posterior urethra, and this change might reduce the excitatory signals from the urethrodetrusor facilitating reflexes. Necrosis and apoptosis within a limited area also have been described. Thus, there is likely more than one basis for the therapeutic effect of TUMT.
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Affiliation(s)
- M Brehmer
- Department of Urology, Huddinge University Hospital, Sweden.
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Minnee P, Debruyne FM, de la Rosette JJ. Transurethral microwave thermotherapy in benign prostatic hyperplasia. Curr Urol Rep 2000; 1:110-5. [PMID: 12084324 DOI: 10.1007/s11934-000-0045-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article reviews the available literature and data on high-energy transurethral microwave therapy (TUMT) in the treatment of benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS). TUMT is a safe, durable, (1-hour) procedure, without the need for anesthesia. Emphasis is made on the effect and mechanism of TUMT, the different devices available including different energy protocols, and accompanying clinical results.
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Affiliation(s)
- P Minnee
- Department of Urology, University Hospital Nijmegen, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
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Frymann R, Cranston D, O'Boyle P. A review of studies published during 1998 examining the treatment and management of benign prostatic obstruction. BJU Int 2000; 85 Suppl 1:46-53. [PMID: 10756706 DOI: 10.1046/j.1464-410x.2000.00046.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- R Frymann
- Department of Urology, Southmead Hospital, Bristol, UK
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ROBERTS ROSEBUDO, JACOBSEN STEVENJ, JACOBSON DEBRAJ, RHODES THOMAS, GIRMAN CYNTHIAJ, LIEBER MICHAELM. LONGITUDINAL CHANGES IN PEAK URINARY FLOW RATES IN A COMMUNITY BASED COHORT. J Urol 2000. [DOI: 10.1016/s0022-5347(05)67984-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- ROSEBUD O. ROBERTS
- From the Department of Health Sciences Research, Sections of Clinical Epidemiology and Biostatistics, and the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and the Epidemiology Department, Merck Research Laboratories, Blue Bell, Pennsylvania
| | - STEVEN J. JACOBSEN
- From the Department of Health Sciences Research, Sections of Clinical Epidemiology and Biostatistics, and the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and the Epidemiology Department, Merck Research Laboratories, Blue Bell, Pennsylvania
| | - DEBRA J. JACOBSON
- From the Department of Health Sciences Research, Sections of Clinical Epidemiology and Biostatistics, and the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and the Epidemiology Department, Merck Research Laboratories, Blue Bell, Pennsylvania
| | - THOMAS RHODES
- From the Department of Health Sciences Research, Sections of Clinical Epidemiology and Biostatistics, and the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and the Epidemiology Department, Merck Research Laboratories, Blue Bell, Pennsylvania
| | - CYNTHIA J. GIRMAN
- From the Department of Health Sciences Research, Sections of Clinical Epidemiology and Biostatistics, and the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and the Epidemiology Department, Merck Research Laboratories, Blue Bell, Pennsylvania
| | - MICHAEL M. LIEBER
- From the Department of Health Sciences Research, Sections of Clinical Epidemiology and Biostatistics, and the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and the Epidemiology Department, Merck Research Laboratories, Blue Bell, Pennsylvania
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