The role of day case surgery is expanding worldwide. This is the result of the realization by managers of its economic efficiency, by the medical staff of their ability to treat large volume of patients quickly and efficiently and by the patients themselves that effective minor surgery can be undertaken without the need for a night in hospital. [1].

For decades, transurethral resection of the prostate (TURP) has been considered the ‘‘gold standard’’ surgical intervention for patients with LUTS/BPH. Following TURP, 70–85% of patients experience improvement of symptoms. However, TURP can be associated with significant morbidity, including TUR syndrome, intraoperative and postoperative bleeding with need for blood transfusions, and acute myocardial infarction. The relatively high incidence of complications traditionally associated with TURP has driven the development of novel surgical/minimally invasive treatments for LUTS/BPH. In last 15 years there has been a significant change in the management of lower urinary tact symptoms (LUTS) presumably secondary to benign prostatic hyperplasia.

Here, we discuss several alternatives to TURP, which can be used to treat LUTS/BPH, in particular the TURP analogues such as bipolar transurethral resection in saline (TURIS), transurethral vaporization of the prostate (TUVP) and holmium laser resection / enucleation (HoLRP/ HoLEP), energy-based thermal ablation with transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT) and Photoselective laser vaporization (PVP), botulinum toxin injections, and mechanical intervention with intraprostatic stents. New surgical and minimally invasive treatments for LUTS/BPH should have a comparable efficacy and durability to TURP, but better safety outcomes, such as fewer perioperative and postoperative complications, which reduce the length of hospital stay, allowing the procedure to be done on day case basis. Furthermore, the new techniques should be less costly.

Transurethral Microwave thermotherapy (TUMT)- TUMT is a heat-based therapy based on increasing
ntraprostatic temperatures greater than 45oC, which cause coagulation necrosis in the targeted peri-urethral glandular tissue of the transition zone. The heat is delivered through a Foley type self retaining catheter with a microwave antenna. This heat penetrates within the prostate to about 15 mm. Several devices are available, with the main difference between them being the degree of energy delivered, the cooling system, and design of the antenna. TUMT is effective in relieving LUTS and improving voiding parameters, according to studies with at least 1 year of follow-up. In sham-controlled studies, symptom scores decreased between 40% and 70%, whereas peak urinary flow rates increased 14% to 60% (2). The incidence of major complications associated with microwave treatment has been found lower than with TURP. Prolonged post-operative catheterization times, urinary tract infections and post-treatment irritative symptoms such as dysuria, however are more common reported complications. The most important advantage of TUMT is that it can be performed in an outpatient setting within an office without the need for anesthesiologists.

Transurethral needle ablation (TUNA)-
TUNA is another temperature based minimally invasive treatment for prostate that uses the thermal properties of radiofrequencies. The TUNA catheter is fitted with 2 deployable needles angled 40 degrees from each other. The needles deliver thermal energy by emitting 460- to 465-KHz signals from an automated generator that maintains a target temperature of more than 450C at the periphery and approximately 100 degree C at the centre. Coagulation necrosis can be achieved at a mean 3 mm from the tip of the needles through agitation of water molecules causing friction and subsequent heat. Large prostate may need multiple puncture for complete treatment. Depth of penetration by the deployed needles is preset and based on volume assessment and urethral length measurements. Needle length can be controlled with extendible teflon shields and generator wattage can be changed to avoid unwanted damage to surrounding structures, such as the urethra and rectum.

TUNA device is inserted with a 0o optical lens, under

direct vision similar to a rigid 18F cystoscope under local anaesthesia. The length of needle deployment in prostate is calculated with TRUS. Pathological studies demonstrate that the thermal injury may extend 5 to 6 mm beyond the tip of the deployed needle; transversely the lesion created during ablation may cover a distance of 10 mm. One lesion usually is performed per 20 g of prostate tissue. Depending upon the size of prostate gland (20 t0 75 g), one to three planes of treatment are created, beginning 1 cm from the bladder neck and continuing at 1.5 cm increments until approximately 1 cm proximal to the verumontanum. Patient is discharged home with or without catheter on the same day.

TUNA is well tolerated with only negligible discomfort and significant symptom score improvements. There is lower risk of adverse events compared with other more invasive treatments. Effects on sexual function are minimal with lower rates of retrograde ejaculation and erectile dysfunction rates in approximately 3% of cases (3).

Transurethral balloon dilatation of prostate (TUBDP)-
The hypothesis behind BDP was that rupturing the anterior fibromuscular stroma would reduce the resistance and improve the symptoms. However the randomized study of BDP and diagnostic cystoscopy showed that BDP was no more effective than cystoscopy at relieving LUTS. BDP therefore has fallen out of favor as an alternative for managing LUTS/BPH (4).

Prostatic stents-
Stenting the prostatic urethra to relieve LUTS was first described in 1980. Several stents has been developed since then. Stents have been classified into temporary and permanent
1) Temporary- These remain in the urethral lumen and can be replaced at the intervals. They are used as an alternative to indwelling catheter for short term relief of prostatic obstruction either in patients with contraindications for surgery or in patients who are awaiting surgery or in patients who do not want to undergo surgery. They are usually of 4 types: spiral stents made of coiled stainless steel wire, self expandable nitinol stents, polyurethrane stents and biodegradable stents which breakdown into small fragments and are excreted per urethra. These stents allow normal voiding and are easy to insert and remove on an outpatient basis. Most promising application of these stents may be for preventing urinary retention as a results of thermally induced edema after TUMT. Urgency, frequency and encrustation and stent migration are the commonly seen complications of these stents. The drawbacks of these stents are that they require a specialist follow-up and are very expensive if multiple replacements are needed (5).
2) Permanent - These stents are meant for definitive treatment, they get incorporated into the urethral wall and these in turn avoids encrustation and migration. They are used in patients with urinary retention or in patients with absolute contraindication for TURP. They are made up of self-expandable woven tubular mesh that maintains its position by outward external pressure. Pain, storage symptoms and incontinence are the few associated complications. Important drawback of stent is that it is difficult to remove (6).

Urethral fluid balloon-based thermotherapy-
It is based on principle of producing heat-induced coagulative necrosis and subsequent ablation of obstructing hyperplasic tissue. It uses a closed loop catheter with two balloons, the anchoring balloon within the bladder is the proximal one which keeps the catheter in place and cigar shaped treatment balloon stretches and treat the prostatic urethra. Water at 60 – 70oC temperature is circulated through the dilated treatment balloon. The remainder of the catheter shaft is insulated to prevent damage to non-target tissue. Temperature ideally is limited to 43oC for the urethra. The advantage of procedure is that it can be performed in a single 45 min office session under local anaesthesia. Major drawback of procedure is a need for post-procedural catheterization since immediate tissue ablation is not produced (7).

Transurethral ethanol ablation of prostate (TEAP)-
It was initially introduced as a transperineal injection with phenol being the agent injected. The disadvantage of this was extraprostatic leakage of agent that led to higher incidence of adverse events. Transurethral method of injecting ethanol has been found to be a safer approach. Prostatic capsule was found to act as a relative barrier to ethanol diffusion after transurethral injection. Considerable lobular volume of necrosis (42%) was found. In a European multicenter study average reduction in prostatic volume of 16% was found and requirement for TURP was found in 7% of patients at 1 year follow-up (8).

Rotoresection of prostate-
It involves an axially adjustable actively rotating crank with a milling-head spiked electrode fitting into a specifically designed working element. It is driven by a micro motor which transmits rotation to the electrode. In a prospective study AUA symptom score decreased form 20.5 + 3.8 to 1.12 + 1.56 and the Qmax rose from 8.7 + 2.1 to 21.8 + 8.5 ml/sec (9).

Botox injection-
Botulinum toxin A (BTA) injection is effective to control both mechanical and dynamic components of BPH. This conclusion is based on studies that chemical denervation using BTA causes subsequent atrophy of the gland, and cholinergic stimulation causes prostatic stromal smooth muscle contraction and that BTA blocks acetylcholine release at the neuromuscular junctions and in autonomic neurons. BTA induces prostate apoptosis and reduces prostate volume in animals and human. Neither systemic complications, such as respiratory depression or hyposthenia, nor local complications, e.g. gross hematuria, UTI, urinary retention or urethral stricture, occurred after BTA injection. The injection method was safe and simple, and no patient needed narcotic analgesics after the injection. With a dose of 100 or 200 U of BTA injected into the prostate, 31 of 41 men had 30% improvement in LUTS and QoL indices. The effect was prompt, and was maintained for 6 months.

There has been no report of local or systemic complications with prostate BTA injection. However, a long-term follow-up is needed to confirm its safety regarding the risk of developing prostate cancer (10).
Holmium Laser Enucleation of Prostate (HoLEP): Holmium laser enucleation of the prostate (HoLEP) continues to be one of the most rigorously analyzed surgical techniques for the treatment of men with obstructive symptoms of BPH (11).
Gilling et all popularized the use of Holmium laser for resection of prostate (11). More recently for enucleating very large prostate HoLEP has been described. In one study the average procedure time was found to be 134 mins (range25 to 470 mins), mean specimen weight was 68gms (3 to 376gms), the hospital stay was on average 1.1 day. The need for postoperative transfusion is significantly low. The episodes of TURP Syndrome were never experienced. The length of hospital stay, time to catheter removal and number of adverse effects are significantly lower with HoLEP than TURP. Holmium laser has also been used for vaporization of prostate. Disadvantage of vaporization is that it can be used for small size prostates and retreatment rate is significantly high (12, 13).
The main advantage of Holmium laser over other lasers is its versatility. It can be used for bladder tumor resection and also for stone fragmentation. It has been concluded that HoLEP is a significant addition to the surgical armamentarum of urologist. HoLEP has been found to be safe in patients on anticoagulant medication, patients with prior history of IHD and patients with coagulopathy (14).

However The HoLEP procedure requires steep learning curve and early attempts can be associated with unpleasant complications such as bladder mucosal injury. HoLEP with tissue Morcellation does not appear to alter the ability to detect prostatic cancer in pathological specimens. There is no difference in sexual function by comparing erectile function or orgasmic function domains comparing HoLEP and TURP.
Potassium titanyl phosphate (KTP) laser:
High-powered potassium titanyl phosphate laser has been recently found to be a user friendly option over TURP. KTP laser uses a higher power output than previous lasers to vaporize BPH tissues. KTP energy can be delivered to the prostate in the noncontact mode without significant loss of energy. This causes heating of the tissue, resulting in instant vaporization. Constant irrigation washes out the vapour while limiting the depth of thermal penetration to 1–2 mm. This is in contrast to the holmium laser which is highly absorbed by the irrigating medium,causing an air–tissue bubble interface. The use of postoperative catheters is usually at the discretion of the surgeon. A significant proportion of patients can be totally catheter free [15]. Catheters when used for short periods may be useful till recovery from spinal anaesthesia or in patients operated in the evening. In one centre, more than 65% of the patients are treated without postoperative catheters (unpublished data). The increasing profile of safety demonstrated with PVP along with its remarkable haemostatic properties have encouraged the use of PVP in patients with ischemic heart disease ( patient on anticoagulants) with great success (15).
Green Light laser has made day-case prostatectomy a true prospect and may consign TURP and open prostatectomy to the annals of history. The procedure is virtually bloodless, safe associated with short period of catheterization and can be carried out as a day case procedure. Early symptomatic and flow rate improvement is similar to TURP. The main drawbacks of KTP laser are the high set up costs and lack of tissue for analysis (16).
 

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