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Use of Transurethral Needle Ablation of the Prostate for Acute Urinary Retention
0022-5347/02/1683-1107/0 THE JOURNAL OF UROLOGY® Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 168, 1107, September 2002 Printed in U.S.A.
DOI: 10.1097/01.ju.0000023407.26529.a6
USE OF TRANSURETHRAL NEEDLE ABLATION OF THE PROSTATE FOR ACUTE URINARY RETENTION JAMES MEYER From Urologic Physicians, Minneapolis, Minnesota KEY WORDS: prostatic hyperplasia, catheter ablation, urinary retention
Traditionally the treatment of acute urinary retention secondary to benign prostatic hyperplasia (BPH) would include transurethral prostatectomy, ␣-blockade and intermittent or long-term catheterization. My experience includes 30 patients in acute urinary retention secondary to BPH who failed ␣-blockade and were then successfully treated with transurethral needle ablation. A representative case is described. CASE REPORT
A 74-year-old white male presented to the emergency department with urinary retention. A catheter was placed and 1,000 cc urine was collected. Medical history included gradually progressive obstructive urinary symptoms that had not been treated with ␣-blockers or other medication. The patient also had previously undergone hydrocelectomy. He was discharged home with an indwelling Foley catheter. The patient presented to our office for followup in October 2001. At that time the indwelling catheter was removed and flexible cystoscopy was performed. A long and obstructive prostate was observed with primarily lateral lobe obstruction and a small median lobe. Grade 3 to 4 trabeculation of the bladder was noted. There were no bladder tumors. The prostatic urethra measured 4 cm. in length. The catheter was not reinserted and the patient was given a trial of tamsulosin. While on tamsulosin therapy, he went into retention a second time and again underwent catheterization, which yielded 400 cc urine. Because of persistent retention and failure to improve with conservative therapy, the patient was evaluated for transurethral needle ablation of the prostate. Preoperative workup revealed a prostate specific antigen of 3.0 ng./ml., transverse diameter of the prostate of 5.2 cm. and prostate volume of 40 cm.3. On October 12, 2001 the patient underwent transurethral needle ablation in our office under pure local anesthesia. Preoperative medication included 10 mg. extended release oxybutynin starting 2 nights prior to the procedure, and rofecoxib and levofloxacin starting the night prior to the procedure. Before beginning the procedure 40 cc 2% cool lidocaine solution was placed in the bladder and the catheter was removed. Lidocaine jelly was then placed per urethra. The patient was also given 10 mg. diazepam by mouth and 100 mg. meperidine by mouth 1 hour prior to the procedure. The patient then underwent transurethral needle ablation with the PROVu disposable catheter and generator (Medtronic, Minneapolis, Minnesota). The number of treatment planes was Accepted for publication April 5, 2002.
determined by the size and shape of the prostate. In this instance 9 treatments were indicated, 4 to each lateral lobe and 1 to the median lobe. The needle length was set to 20 mm. due to the transverse diameter of the prostate. Needle length was calculated using the manufacturer’s recommendation. The entire procedure took 55 minutes to complete. At the end of the procedure an 18Fr Foley catheter was placed, gently irrigated and then connected to a leg bag. The patient was released to a family member, and for 5 days he continued the antiinflammatory and antibacterial agents. I usually recommend that the Foley catheter remain indwelling for 2 weeks when the patient is in urinary retention. However, this particular patient requested that the catheter be removed at 7 days, and he was able to void satisfactorily at that time. At 6 weeks postoperatively he was voiding well and was pleased with the procedure. He had discontinued ␣-blockade. He reported no adverse reactions, and maintained sexual function and bladder control. DISCUSSION
Transurethral needle ablation of the prostate is a minimally invasive treatment approved for symptomatic BPH. This procedure treats the interior tissue of the prostate by ablating the tissue using low level radiofrequency energy but with intraprostatic temperatures of 110C. The prostate tissue mass is decreased while the prostatic urothelium and prostate envelope are preserved. A small probe is inserted through the urethra and 2 small electrodes are deployed into the prostate tissue. Using a computerized generator to monitor temperature and treatment zone, radiofrequency energy is emitted, heating the prostate tissue and causing it to shrink. The transurethral needle ablation device is manufactured specifically for BPH, and I have found that it can definitely be used in patients in acute urinary retention. In addition, the procedure can be performed in an office setting with the patient under local anesthesia. CONCLUSION
This patient represents 1 of 30 men in acute urinary retention secondary to BPH whom I have treated with transurethral needle ablation. These patients had been in urinary retention requiring Foley catheter drainage, and all had failed ␣-blockade treatment prior to undergoing transurethral needle ablation. I believe that transurethral needle ablation, with its minimal side effects, speed, office setting and Medicare reimbursement, is well indicated for the treatment of urinary retention secondary to BPH.
1107
Vol. 168, 1107, September 2002 Printed in U.S.A.
DOI: 10.1097/01.ju.0000023407.26529.a6
USE OF TRANSURETHRAL NEEDLE ABLATION OF THE PROSTATE FOR ACUTE URINARY RETENTION JAMES MEYER From Urologic Physicians, Minneapolis, Minnesota KEY WORDS: prostatic hyperplasia, catheter ablation, urinary retention
Traditionally the treatment of acute urinary retention secondary to benign prostatic hyperplasia (BPH) would include transurethral prostatectomy, ␣-blockade and intermittent or long-term catheterization. My experience includes 30 patients in acute urinary retention secondary to BPH who failed ␣-blockade and were then successfully treated with transurethral needle ablation. A representative case is described. CASE REPORT
A 74-year-old white male presented to the emergency department with urinary retention. A catheter was placed and 1,000 cc urine was collected. Medical history included gradually progressive obstructive urinary symptoms that had not been treated with ␣-blockers or other medication. The patient also had previously undergone hydrocelectomy. He was discharged home with an indwelling Foley catheter. The patient presented to our office for followup in October 2001. At that time the indwelling catheter was removed and flexible cystoscopy was performed. A long and obstructive prostate was observed with primarily lateral lobe obstruction and a small median lobe. Grade 3 to 4 trabeculation of the bladder was noted. There were no bladder tumors. The prostatic urethra measured 4 cm. in length. The catheter was not reinserted and the patient was given a trial of tamsulosin. While on tamsulosin therapy, he went into retention a second time and again underwent catheterization, which yielded 400 cc urine. Because of persistent retention and failure to improve with conservative therapy, the patient was evaluated for transurethral needle ablation of the prostate. Preoperative workup revealed a prostate specific antigen of 3.0 ng./ml., transverse diameter of the prostate of 5.2 cm. and prostate volume of 40 cm.3. On October 12, 2001 the patient underwent transurethral needle ablation in our office under pure local anesthesia. Preoperative medication included 10 mg. extended release oxybutynin starting 2 nights prior to the procedure, and rofecoxib and levofloxacin starting the night prior to the procedure. Before beginning the procedure 40 cc 2% cool lidocaine solution was placed in the bladder and the catheter was removed. Lidocaine jelly was then placed per urethra. The patient was also given 10 mg. diazepam by mouth and 100 mg. meperidine by mouth 1 hour prior to the procedure. The patient then underwent transurethral needle ablation with the PROVu disposable catheter and generator (Medtronic, Minneapolis, Minnesota). The number of treatment planes was Accepted for publication April 5, 2002.
determined by the size and shape of the prostate. In this instance 9 treatments were indicated, 4 to each lateral lobe and 1 to the median lobe. The needle length was set to 20 mm. due to the transverse diameter of the prostate. Needle length was calculated using the manufacturer’s recommendation. The entire procedure took 55 minutes to complete. At the end of the procedure an 18Fr Foley catheter was placed, gently irrigated and then connected to a leg bag. The patient was released to a family member, and for 5 days he continued the antiinflammatory and antibacterial agents. I usually recommend that the Foley catheter remain indwelling for 2 weeks when the patient is in urinary retention. However, this particular patient requested that the catheter be removed at 7 days, and he was able to void satisfactorily at that time. At 6 weeks postoperatively he was voiding well and was pleased with the procedure. He had discontinued ␣-blockade. He reported no adverse reactions, and maintained sexual function and bladder control. DISCUSSION
Transurethral needle ablation of the prostate is a minimally invasive treatment approved for symptomatic BPH. This procedure treats the interior tissue of the prostate by ablating the tissue using low level radiofrequency energy but with intraprostatic temperatures of 110C. The prostate tissue mass is decreased while the prostatic urothelium and prostate envelope are preserved. A small probe is inserted through the urethra and 2 small electrodes are deployed into the prostate tissue. Using a computerized generator to monitor temperature and treatment zone, radiofrequency energy is emitted, heating the prostate tissue and causing it to shrink. The transurethral needle ablation device is manufactured specifically for BPH, and I have found that it can definitely be used in patients in acute urinary retention. In addition, the procedure can be performed in an office setting with the patient under local anesthesia. CONCLUSION
This patient represents 1 of 30 men in acute urinary retention secondary to BPH whom I have treated with transurethral needle ablation. These patients had been in urinary retention requiring Foley catheter drainage, and all had failed ␣-blockade treatment prior to undergoing transurethral needle ablation. I believe that transurethral needle ablation, with its minimal side effects, speed, office setting and Medicare reimbursement, is well indicated for the treatment of urinary retention secondary to BPH.
1107