**7.6 Minimally invasive surgical therapies**

Standard operations are *TURP* in small (≤80-100mL) or open prostatectomy in large prostates (>80-100mL). Minimally invasive, alternative surgeries may be considered in selected men and offer advantages regarding risk of bleeding, duration of catheterization, or maintenance of sexual function. (Gabuev and Oelke 2011).

*Transurethral incision of the pro*state (TUIP) or bladder neck incision is recommended for smaller gland (weigh <25g) and has been found to be less invasive than TURP (Orandi 1990). TUIP has several advantages over TURP, such as a lower incidence of complications,

Benign Prostate Hyperplasia and Chronic Kidney Disease 369

Recently Woo *et.* al reported the use of a Prostatic Urethral Lift (PUL) procedure, which is a novel, minimally invasive treatment for symptomatic benign prostatic hyperplasia (BPH). PUL aims to mechanically open the prostatic urethra without ablation or resection, with patients reporting sustained symptom relief for 12 months with minimal morbidity (Woo,

Tadalafil and other phosphodiesterase type 5 (PDE5) inhibitors have demonstrated beneficial effects on smooth muscle relaxation, smooth muscle and endothelial cell proliferation, nerve activity, and tissue perfusion that may impact LUTS (Andersson, de Groat et al. 2011). Consistent evidence of improvements in LUTS has been shown with PDE5-Is, either alone or in combination with α-blockers (Martinez-Salamanca, Carballido et al. 2011). However, urodynamic results or objective measures of urinary flow are lacking

De Souza *et* al, investigated the effects of *Orbignya speciosa*, a nanoparticle extract, newly developed phytotheraphy that can be safely used on the management of BPH (de Souza,

In our country (Portugal) a recent study led by Pisco *et*. al, aimed to evaluate whether prostatic arterial embolization could be a feasible way to treat lower urinary tract symptoms associated with benign prostatic hyperplasia. Their preliminary results and short-term follow-up suggest good symptom control without sexual dysfunction associated with a

Rick *et* al, in recent times used growth hormone-releasing hormone (GHRH) in animal models. They concluded that GHRH antagonists can lower prostate weight in experimental BPH with significant reductions in protein levels of IL-1β, NF-κβ/p65, and cyclooxygenase-2 (COX-2), suggesting that GHRH antagonists should be considered for further investigation

It is important in a near future to characterize a *clinical phenotype* of BPH; measure disease severity and outcomes; design clinical trials; study concepts for drug therapy, behavioral

Benign prostatic hyperplasia and chronic kidney disease are two common and prevalent entities in elderly men. It has been reported in several studies that threads of evidence suggest that BPH is a risk factor for chronic kidney disease. An average of 13,6% patients presenting to urologic clinics for the treatment of BPH had renal failure. The low occurrence of CKD in BPH clinical trials should not be used to infer a weak association between these two disease processes (Rule et al., 2005). From our own experience we deem that the average of patients with BPH and some degree of renal disease can be higher, mostly because older men most of the times ignore their micturition problems and seek for clinical help just in a

Although BPH is not a life-threatening condition, the impact BPH on quality of life (QoL) can be significant and should not be underestimated. On the other hand CKD is an

and lifestyle interventions and additional intervention therapies (AUA 2010).

important medical problem that can even be critical (Fox, Larson et al. 2004)

Chin et al. 2011).

Palumbo et al. 2011).

**9. Conclusion** 

later degree of BPH.

(Martinez-Salamanca, Carballido et al. 2011).

as therapy for BPH (Rick, Schally et al. 2011)

reduction in prostate volume (Pisco, Pinheiro et al. 2011).

minimal risk of bleeding and blood transfusion, decreased risk of retrograde ejaculation, shorter operating time and hospital stay, and an importantly higher long-term failure rate.

*Transurethral electrovapori*zation (TUVP) is a modification of TURP and TUIP, employing high electrical current to vaporize and coagulate the obstructive prostate tissue. Long-term efficacy is comparable with TURP, but high number of patients has been found to experience irritative side effects (Desautel, Burney et al. 1998).

*Transurethral needle ablation* (TUNA) is a simple and relatively inexpensive procedure which uses a needle to deliver high-frequency radio waves to destroy the enlarged prostatic tissue. TUNA is a successful treatment for small-sized gland and it poses a low or no risk for incontinence and erectile dysfunction (Ramon, Lynch et al. 1997).

*Transurethral microwave thermother*apy (TUMT) heats the prostate using a microwave antennae mounted on a urethral catheter (Thorpe and Neal 2003). TUMT has been found to be safe and cost effective, with reasonable improvement in urine flow rate and minimal impairment on sexual function (Richter, Rotbard et al. 1993).

*Transurethral ethanol ablation of the prostate* (TEAP) has been recently introduced as a minimally invasive alternative treatment for patients with BPH. TEAP produces necrotic effect on prostatic tissues, leading to fibrosis and shrinkage. It is an effective minimally invasive treatment option for medically high-risk symptomatic patients with BPH that can be performed as an outpatient procedure under regional anesthesia (El-Husseiny and Buchholz 2011).

*Laser prostatectomy*: four types of lasers have been used to treat LUTS, namely neodymium: yttrium-aluminum-garnet (Nd: YAG) laser, holmium YAG laser (Ho:YAG), potassium titanyl phosphate (KTP), and diode laser. It has been found to be safe and effective technique, with significant improvement in urinary flow rates and symptoms. Short surgery time, shorter catheter use, minimal blood loss and fluid absorption, decreased hospital stay, low erectile dysfunction rates, and bladder neck contractures are few of the advantages of laser prostatectomy over the TURP and other conventional techniques (Donovan, Peters et al. 2000; Bent, Kane et al. 2006). Laser surgery is specially indicated in patients receiving anticoagulant therapy that want to maintain ejaculation or are unfit for TURP.

*Transrectal HIFU* (high intensity focus ultrasonography) therapy is the only technique that provides non-invasive tissue ablation; however, general anesthesia or at least heavy intravenous sedation is required. Long-term efficacy is limited, with a treatment failure rate of approximately 10% per year.Significant increase in uroflow and a decrease in postvoid residual volume have been observed, but the cost is three times higher than that of TURP (Madersbacher, Kratzik et al. 1993).
