الفهرس 
Anatomy & Pathophysiology of the prostateOnly 14 pages are availabe for public view
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Abstract
The range of therapeutic options for the management of BPO continues to widen as technology continues to evolve and improve.
Increased choices create the increased need for clarity in selection and application of various treatment options based on the clinical outcomes, morbidity, and technical improvement of these technologies. (Baba et al., 2006)
► Clinical practice guidelines (CPGs) recommendations for MITs :-
Clinical practice guidelines (CPGs) have been developed to help urologists and patients decide about appropriate health care for specific clinical circumstances.
Table (07.01): Presents the current recommendations of the most popular CPGs. Recently introduced minimally invasive treatments (MITs) for BPH. (Bouchier-Hayes et al., 2006)
(Rosette et al., 2008)
► Efficiency and Durability of MITs :-
TURP remains the gold standard for minimally invasive treatments of BPH, but many new MITs have demonstrated similar outcomes than TURP in terms of efficacy and durability. (Hoffman et al., 2007)
Table (07.02): presents a systematic review of all available randomized comparative trials (RCTs) on MITs attempted to quantify the therapeutic efficacy and the clinical results at 12 months after treatment based on the highest quality study for each of the treatment options. (Bouchier-Hayes et al., 2006)
(Rosette et al., 2008)
Data comes from meta-analyses of RCTs showed that an ablative therapy like TURP or vaporizing laser therapy like PVP or Bipolar electro-therapy like PKVP should be advocated as the first-line of treatment for patients with an absolute surgical indication. (Erturhan et al., 2007)
Table (07.03): Presents the success rate of MITs on only patients in retention; the success is defined as the percentage of patients who regained the ability to void spontaneously. (Silva et al., 2008)
(Rosette et al., 2008)
► Jean’s Algorithm for MITs selection :-
Jean J.M.C.H. de la Rosette and collogues presented their approach in the Urological clinic of North America (May 2008) for MITs selection in treatment of BPH.
(Figure 07.01) showed the algorithm for the instrumental treatment of lower urinary tract obstruction outlines.
Patients are classified on the basis of operative risk of patients, because TURP morbidity was the main reason for the search of alternative treatment modalities.
Grades (1, 2, 3, and 4) have been allocated to the procedures based on clinical efficacy, morbidity, durability, and strength of evidence.
When two procedures were considered to be equally useful, were been graded with the same number and the first alternative has the number 1.
WIT, HIFU, BONT-A, and Laparoscopic prostatectomy were not included in this algorithm because of limited data or decline in their use in the clinical practice.
The present algorithm is indicative, but patients’ preferences (including interest in sexual function and peri-operative morbidity) also should be involved in treatment selection. Also other factors are involved as the availability of MIT and urologists’ beliefs.
(Rosette et al., 2008)
Figure (07.01): Algorithm for instrumental treatment of lower urinary tract obstruction. (Rosette et al., 2008)
► Costs :-
The introduction of new technology in health care sometimes is charged as one of the major causes of increasing costs.
Different economic models evaluating the cost-effectiveness of MITs for BOO have been introduced. (Stovsky et al., 2006)
High costs frequently are cited as a major drawback of the new Laser techniques.
Performance of treatment on an outpatient basis represents a critical factor that reduces the direct cost and renders some MITs economically advantageous. However, this benefit may be balanced by the higher re-treatment rate of most ambulatory MITs.
Data from the Urologic Diseases in America BPH project showed that BPH therapy trends are moving away from the gold standard operation of TURP and toward less-invasive pharmacologic options and MIT in an outpatient setting as TUNA and TUMT. (Wei et al., 2005)
Disantostefano and colleagues showed that the best treatment for BPH varies depending on the value that individuals and society place on costs and consequences, including disease progression, clinical outcomes, hospitalization, and catheterization time.
In addition, the cost-effectiveness of all techniques depends on the durability, costs of complications, costs of re-treatment and the different reimbursement systems in different countries.
Therefore, it is difficult to draw solid conclusions that are applicable to every country.
(Disantostefano et al., 2007)
► Final words :-
In contrary with other medical diseases, BPH mangement has numerous improving modalities of treatment with different techniques.
Unfortunately, each of which has a characteristic advantage with some disadvantages as regard safety, efficiency, durability and cost-effectiveness.
TUNA, TUMT and Intra-prostatic stents have been established as valuable ambulatory treatments mainly in patients with poor surgical fitness. With their clinical efficiency to be in between medical treatments and surgical management. Also they have acceptable safety and cost-effectiveness. But with low durability and mostly need re-treatment.
Laser techniques, mainly the evolving challenging HoLEP and Diode Laser vaporization are trying to replace the Gold standard TURP, by their safety, efficiency, durability. But the cost-effectiveness is their main drawback.
The introduction of the evolving bipolar technology presents the improving bipolar plasma kinetic resection and vaporization of the prostate (TURis & PKVP).
They are unique in being extremely safe, efficient, durable and have wide range of use with acceptable cost-effectiveness, spread, acceptance by hospitals and urologists.
TURis and PKVP have actually reinforced the position of TURP as the cornerstone of all minimally invasive surgical management of BPH.