Minimally Invasive Procedures and Medical Management—Their Relative Merits in Treating Lower Urinary Tract Symptoms of Benign Prostatic Hyperplasia

Abstract

Evidence is reviewed supporting the safety and efficacy of minimally invasive transurethral microwave thermotherapy and medical management in patients with benign prostatic hyperplasia. Recent data indicate more pronounced long-term beneficial effects of microwave treatment. α-Blockade, however, offers more rapid onset of action than does microwave treatment. Neoadjuvant and adjuvant α-blocker therapy can accelerate symptom and flow rate improvement in patients undergoing microwave treatment. Compared with medical management, microwave treatment also appears to possess greater versatility, allowing patients who fall within a broad range of baseline symptom severities and prostate sizes to be treated with a high probability of success.

While transurethral resection of the prostate (TURP) continues to be widely regarded as the gold standard for definitive management of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH), nonsurgical alternatives have been gaining increasing prominence in urologic practice. Various types of minimally invasive procedures have been introduced that are designed to destroy obstructive prostatic tissue by application of thermal energy. The most extensively characterized of these minimally invasive modalities is transurethral microwave thermotherapy (TUMT). This form of treatment affords lasting symptom relief, increased peak urinary flow rate (Q_max), and enhanced quality of life (QOL) in a single 1-hour outpatient treatment session under topical anesthesia.¹ Recent observations also suggest the feasibility of treatment sessions shorter than 1 hour.² Morbidity associated with microwave treatment is low.

LUTS of BPH can often be satisfactorily managed with drug therapy. Evidence reported as early as the mid-1970s revealed that symptomatic relief could be obtained by pharmacologic blockade of α-adrenergic receptors. In the late 1990s, α-blockers have become the most frequently selected form of BPH therapy. Emerging in the 1990s, inhibition of 5α-reductase enzyme is another pharmacologic strategy for BPH management. The objective of this form of treatment is to reverse androgen-mediated prostatic hyperplasia.

This review focuses on evidence supporting the clinical utility of minimally invasive microwave thermal treatment, compared with medical management by α-blockade or 5α-reductase inhibition. The scientific basis and therapeutic rationale for microwave treatment are delineated, including the importance of thermal dose and precise targeting of thermal energy. Salient functional differences between available microwave treatment systems are highlighted. Clinical experience with the most commonly prescribed α-blockers and finasteride is summarized. Recent data directly comparing microwave treatment with α-blockade are reviewed, including their implications for appropriate patient selection.

Microwave Treatment

The objective of TUMT is thermoablation of the obstructive prostatic tissue without harm to nontarget tissues. Microwave radiation is emitted from an intraurethral antenna, resulting in heat generation. If the heat is sufficient in magnitude and duration, cell death ensues.

Microwave Treatment Systems. Clinically relevant differences exist between microwave treatment systems with respect to microwave antenna design, generated heating patterns, and treatment protocol.³ It is important to consider these differences when evaluating the clinical results. The Prostatron microwave system (Technomed Medical Systems, Lyons, France) has been the subject of numerous clinical studies. In an attempt to enhance treatment efficacy, a “high-energy” modification of the Prostatron treatment protocol has been introduced recently. This protocol is based on Prostasoft version 2.5 software, a modification of the original Prostasoft version 2.0, allowing a maximum of 70 watts of microwave power to be applied during the treatment session. Available data directly comparing the treatment responses between the high- and low-energy Prostatron protocols are limited at this time.

The more recently developed Targis microwave system (Urologix, Inc, Minneapolis, Minn) has also been extensively investigated. The dipole microwave antenna design of this system allows precise targeting of thermal energy (Figure 1).³ As a consequence, intraprostatic temperatures as high as 80°C (176°F) have been measured without significant heating of nontarget tissues, such as the urethra, rectum, and external sphincter.⁴ Other microwave treatment systems investigated in clinical trials include the Microthermer (Laser Electro Optics, London, UK), ECP (Comair, Stockholm, Sweden), Prostalund (Lund Instruments AB, Lund, Sweden), Urowave (Dornier Medizintechnik GmbH, Germering, Germany), Prostcare (Bruker Medical, Wissembourg, France), and Thermex-II (Direx, Petah Tiqva, Israel).

Figure 1.

Precisely targeted microwave energy radiates to prostatic tissue from the antenna of the Targis system.

Thermal Dose. Successful thermoablation depends on delivery of an adequate thermal dose, defined as the tissue temperature attained during treatment multiplied by the duration of exposure to that temperature. Thermal dose cannot be reliably predicted solely on the basis of microwave energy applied, since the actual intraprostatic temperatures achieved also depend on the efficiency of both energy transfer and conversion to heat within the target tissue. Critical variables affecting achieved intraprostatic temperatures include the ability of the microwave antenna to be “tuned” for maximum energy transfer into prostatic tissue, the efficiency of the antenna in delivering microwave energy with minimum loss, the histologic composition of the individual patient’s prostate gland, and the capacity of the prostate gland to dissipate heat via changes in blood flow. Temperatures of 45°C (113°F) or higher for approximately 1 hour have resulted in uniform thermoablation of prostatic tissue.⁵ Higher achieved intraprostatic temperatures have been associated with larger intraprostatic zones of necrosis.⁴

Editorial Comment: Issues in Effectiveness and Durability.

The technology for performing transurethral microwave thermotherapy (TUMT) for the treatment of patients with benign prostatic hyperplasia (BHP) has been available since the early 1990s. Over the last decade, several individuals have examined the clinical utility of this technology. Dr Djavan has done an outstanding job of summarizing the clinical experiences with TUMT. The data are compelling that TUMT improves lower urinary tract symptoms in men with BPH.

The critical issue that is unresolved is the degree of effectiveness. The effectiveness of a minimally invasive or medical therapy can only be determined from randomized, double-blind, placebo sham controlled trials. It is disconcerting that the treatment-related improvement in symptom scores for TUMT reported in the literature at 3 months ranges from 0% to 60%. The reason for this tremendous variability in treatment response rates is unclear. The average treatment-related improvement in symptom scores appears to be about 25%. This is comparable to the treatment-related effectiveness of α-blockers. In Dr Djavan’s personal series, the clinical effectiveness of TUMT was far greater and the effectiveness of α-blockers far less than reports in the literature.

My interpretation of the literature is that, in the short term, the effectiveness of TUMT and α-blockers is quite similar. The durability of effectiveness with α-blockade has been demonstrated consistently, whereas the durability of TUMT is equivocal. If both α-blockers and TUMT have been widely investigated over the last decade, why are α-blockers by far the preferred treatment for patients with BPH among urologists? My explanation for the relatively limited enthusiasm for TUMT is that the technology is expensive, there is a learning curve, and the level of effectiveness and its durability are equivocal. α-Blockade is far less costly, is easier to administer, and the short- and long-term effectiveness are consistent and compelling. TUMT is not my preferred first-line therapy for management of lower urinary tract symptoms of BPH. It is a reasonable treatment option for men who do not tolerate or respond to α-blockers or for a few men who prefer a minimally invasive procedure over a long-term commitment to medical therapy.

Herbert Lepor, MD

Professor and Chairperson of Urology

Professor of Pharmacology

New York University School of Medicine, New York

Clinical evidence underscores the importance of adequate thermal dose. In a study of 52 BPH patients grouped by thermal doses received of either less or more than 5 × 10⁴ °C · second (as derived from measured intraprostatic temperatures), the increase in peak urinary flow 12 months after microwave treatment was significantly greater—by more than 4-fold-in the higher-thermal-dose group (48%) than in the lower-thermal-dose group (11%).⁶ Symptom improvement was also greater in the higher-dose group (51%) than in the lower-dose group (39%), though this difference was not statistically significant. One prospective, randomized clinical study involving 91 consecutive men treated using the Prostatron 2.0 protocol compared outcomes between two groups treated at urethral temperatures below or above 43°C (109.4°F).⁷ While both groups experienced significant symptomatic improvement post-TUMT, only the group exposed to urethral temperatures above 43°C exhibited significant improvement in Q_max.

Targeting. Treatment results also depend on selective targeting of microwave energy. Heating of nontarget tissues may increase the risk of complications and limit treatment efficacy by triggering automatic microwave power shutdowns and/or reducing the patient’s ability to tolerate treatment.⁴ Management of patient discomfort with potent sedoanalgesic medications may also be necessitated by nontarget tissue heating. The Targis microwave treatment system has been shown to possess significantly greater capacity for accurate microwave energy targeting than has the Prostatron system.^3,4

Efficacy. Improvements of 40% to 70% in symptom score and of 14% to 58% in Q_max have been documented in sham-controlled clinical trials of microwave treatment in patients with BPH (Table).^8–16 The QOL scores have also been found to improve significantly.^15–17 A high proportion of patients experience substantial improvement in both relative and absolute terms. For instance, in a recently reported series of 70 patients undergoing targeted microwave treatment, improvements of 50% or more in International Prostate Symptom Score (IPSS), Q_max, and QOL score were achieved by 74%, 71%, and 79% of patients, respectively (Figure 2).¹⁸ Absolute improvements of 10 IPSS points or more, 4 mL/s or greater Q_max amounts, and 2 or higher QOL score points were demonstrated in 67%, 71%, and 80% of patients, respectively (Figure 2).¹⁸ Microwave treatment has also recently been shown to be effective in patients with BPH who were experiencing acute urinary retention.¹⁹

Table 1.

Sham-Controlled Microwave Treatment Clinical Trials

			Symptom decrease at 3 months (%)			Qmax increase at 3 months (%)
Study	System	n	Active	Sham	Pa	Active	Sham	Pa
Bdesha,1993,8	Microthermer	40, 40	63	14 – 16	< .001	19	−9	NS
199410
Ogden,19939	Prostatron 2.0	43	70	10	< .05b	53	7	< .05b
de la Rosette,	Prostatron 2.0	50	55	32	< .05	35	−2	< .05
199411
Mulvin,199412	Prostatron 2.0	40	40	54	NS	14	24	NS
Blute,199613	Prostatron 2.0	115	55c	28c	< .0001	58	27	< .01
			43d	26d	< .01
de Wildt,	Prostatron 2.0	93	66	19	< .001e	46	1	< .001b
199614
Larson,	Targis	169	66	32	< .01f	46	18	< .05f
199815
Roehrborn,	Urowave	220	50	32	<.05	52	19	<.05
199816

Q_max, peak urinary flow rate.

a Except as otherwise indicated, significant difference in response between microwave- and sham-treated patients.

b Significant improvement with transurethral microwave thermotherapy (TUMT) and no significant effect of sham treatment.

c Madsen score.

d American Urological Association score.

e Significant improvement with TUMT (P < .001) and significant effect of sham treatment (P = .003).

f Between-group difference over the 6-month course of follow-up. Adapted from Djavan B et al,⁴⁰ with permission.

Figure 2.

Changes at 12 months versus baseline in International Prostate Symptom Score (IPSS) on (a) percent and (b) absolute bases, peak urinary flow rate (Q_max) [(c) and (d), respectively], and quality of life (QOL) score [(e) and (f), respectively]. Each data point represents the percentage of patients attaining a given outcomes parameter change or greater (that is, greater negative IPSS and QOL score changes and greater positive Q_max changes). Percent changes are shown at decile intervals and absolute changes at intervals of 5, 2, and 1 for IPSS, Q_max, and QOL score, respectively. (Adapted from Djavan B et al,¹⁸ with permission.)

Maximal effects of microwave treatment are observed within 3 to 6 months.¹⁵,–¹⁷ Recent evidence indicates that earlier improvements in symptoms and voiding function can be accomplished by post-treatment placement of a temporary endoprosthetic device, such as an intraurethral prostatic bridge catheter.²⁰

Improvements in symptoms and voiding function after targeted microwave treatment have been found to endure up to at least 36 months.^21,22 In patients treated by the Prostatron 2.0 protocol, the actuarial rate at which patients proceeded to further BPH treatment was 40% at 5 years.

Tolerability. Thus far, few studies have focused systematically on the tolerability of microwave treatment and optimal periprocedural pain management. Nevertheless, it is clear from available evidence that at least with certain microwave treatment systems and protocols, satisfactory pain control requires potent systemic sedoanalgesic medications.²³ This form of pain control may necessitate intensive patient monitoring, entail risk of pharmacologic side effects, and add to treatment costs.

In a study of 288 consecutive patients undergoing the Prostatron 2.0 protocol, 22% required intravenous analgesia with fentanyl citrate.²³ In 6% of these patients, treatment had to be discontinued because of pain that could not be controlled adequately by the intravenous drug regimen. In an additional series of 83 patients undergoing Prostatron 2.0 treatment with or without oral sedation using 10 mg of oxazepam under a single-blinded, prospective, randomized protocol, oral sedation was found to increase significantly the proportion of patients in whom tolerability of treatment was classified as good, based on a visual analog scale (VAS) pain score below 3.3 or the lack of need for pain medication.²³ Patients undergoing Prostatron 2.5 treatment have routinely received 20 to 40 mg of morphine sulfate for pain management before treatment began, supplemented intraprocedurally by 10 mg of diazepam and/or 0.1 mg of fentanyl on patient request.

Such use of potent systemic agents generally has been found unnecessary with the Targis microwave system, presumably at least partly due to this system’s capacity for energy targeting.^15,17 In a recent prospective, randomized, single-blinded clinical trial, 45 patients received either topical urethral anesthesia alone or topical anesthesia with adjunctive intravenous sedoanalgesia during targeted microwave treatment.²⁴ No statistically significant difference was evident between the two groups in the peritreatment profile of VAS pain scores (Figure 3).

Figure 3.

Mean visual analog scale (VAS) pain scores with 95% confidence intervals before, during, and after microwave treatment. P value denotes significance of between-group difference from 0 through 120 minutes. (Adapted from Djavan B et al,²⁴ with permission.)

Catheterization. Transient urinary retention secondary to thermally induced edema generally necessitates temporary urinary catheterization after microwave treatment. The duration of catheterization differs widely, depending on microwave treatment system and protocol. After Prostatron 2.0 treatment, 12% to 36% of patients required catheterization, and the needed catheterization period was up to 1 week in the majority of cases, with some individual patients remaining catheterized longer than 1 month.^9,13,14 With the Prostatron 2.5 protocol, catheterization averaged 16 days, and concomitant irritative voiding complaints endured for a mean of 2 to 3 weeks.²⁵ Catheterization for 1 month or longer was required in 10% of Prostatron 2.5 patients. With the Targis microwave system, the needed catheterization period was 24 hours in 90% of patients.²⁶

Complications. Major complications associated with minimally invasive microwave treatment are substantially more infrequent than those with TURP, thus far. In most cases, complications have proved to be comparatively mild and readily managed. Higher treatment-related morbidity, including hematuria in 76% of patients, has been reported with the Prostatron 2.5 protocol, compared with the 2.0 protocol.²⁵

With the Prostatron 2.0 protocol, adverse effects on sexual function have been minimal. In contrast, after Prostatron 2.5 treatment, retrograde ejaculation has been documented in 33% to 44% of patients who had anterograde ejaculation before treatment. Failure of ejaculation was noted in 22% of sexually active men 6 months after Prostatron 2.5 treatment.²⁵ In one study with the Targis system, loss of ejaculate was encountered in 4% of 125 patients¹⁵; however, in another study with this system, no cases of ejaculatory dysfunction were observed among 154 patients.¹⁷

Patient Selection. While a high proportion of patients respond satisfactorily to microwave treatment, a few patients do not respond to this form of therapy, and even among treatment responders, the magnitude of improvement varies from patient to patient. Pretreatment parameters predictive of successful outcome would be helpful in patient selection. Unfortunately, to date, such parameters have proved largely elusive. In one recent report, higher pretreatment prostate-specific antigen levels were associated significantly with more favorable outcomes, although most patients in this study experienced substantial benefit from microwave treatment.¹⁸ In any case, the lack of significant treatment success predictors underscores the versatility of microwave treatment, which can be successfully administered to patients with differing baseline symptom severity, prostate size, etc. For example, in a study of targeted microwave treatment, the proportion of patients achieving American Urological Association symptom scores lower than 9 was similar among patients with initially moderate symptoms (50%) and those with initially severe symptoms (49%).¹⁵ However, microwave treatment using current technology has not proved to be of significant clinical value in patients with median-lobe hypertrophy.

Drug Therapy

α-Blockade. Prostatic smooth muscle tension is regulated by α-adrenoceptors, and this tension contributes to bladder outlet obstruction. α-Blockers are effective in most BPH patients and are rapid in onset of action. These agents can also be used in some patients as concomitant therapy for both BPH and hypertension. The most frequently prescribed α-blockers are the prazosin analogs terazosin, doxazosin, and alfuzosin and the structurally unrelated compound tamsulosin. A recent meta-analysis indicated that these agents are similar in their effectiveness for relieving symptoms and increasing peak urinary flow rate, though differences exist in side-effect profiles.²⁷

Side effects are a chief limitation of α-blockade use. Consequently, recent research has focused on more “uroselective“ agents, including compounds that inhibit the α_1A-adrenoceptor subtype. However, the receptor(s) mediating BPH are unlikely to be unique to the lower urinary tract; furthermore, α₁-adrenoceptors outside the prostate gland may contribute to LUTS in BPH patients. Nevertheless, available evidence suggests that compounds with higher receptor subtype specificity may be associated with fewer side effects.

5α-Reductase Inhibition. The enzyme 5α-reductase converts testosterone to dihydrotestosterone (DHT) within the prostate gland. DHT promotes prostatic growth, an effect that can be specifically blocked by the 4-azasteroid finasteride. The maximal effects of finasteride are attained over several months of continuous treatment. While not rapid-acting, finasteride does exhibit a favorable safety and tolerability profile.

Efficacy. Improvements achieved with α-blocker treatment are generally smaller than those with microwave treatment. Symptoms were shown to improve more than 30% in nearly twice as many terazosin-treated patients (51%) as placebo recipients (27%), and maximal effects occurred by 6 weeks.²⁶ Terazosin-mediated symptom and peak flow improvements were sustained with continuous treatment for at least 42 months. Terazosin treatment is ineffective in some patients, however. In one recent study, for instance, 6% of patients failed terazosin treatment because of lack of efficacy.²⁶

Doxazosin inhibits all subtypes of the α₁-adrenoceptor and is suitable for simultaneous management of essential hypertension and BPH. Treatment with this agent leads to significant long-term improvement in symptoms and flow rates.^28,29

Significant improvement in symptoms has been reported with alfuzosin treatment.³⁰ A corresponding significant increase in Q_max has been reported in one study but not in others.

Tamsulosin treatment results in symptom and Q_max improvements similar to those with terazosin, doxazosin, and alfuzosin.^31,32 Tamsulosin is comparatively specific to the α_1A-adrenoceptor subtype. This compound can be administered once daily, with reduced need for dose titration.

The effects of finasteride are generally less pronounced than those of α-blockers. Maximal effects exhibit themselves within 6 months and, with continuing treatment, are sustained for at least 6 years. Finasteride treatment has been shown to reduce the occurrence of acute urinary retention and the need for surgical intervention.^33,34

Side Effects. Side effects necessitating treatment discontinuation have recently been reported in 13% to 20% of patients receiving terazosin. Dizziness, its most frequent side effect, has been encountered in 19% to 21% of patients receiving this agent. Discontinuation of doxazosin as a result of side effects has been reported in 10% of patients. In a study of 13,389 patients with BPH, 10% discontinued alfuzosin, most frequently because of side effects.³⁵ In another recently reported large-scale study, the proportion of alfuzosin patients withdrawing because of adverse events was 4%.³⁰

The incidence of dizziness in tamsulosin recipients has been reported to be 3.4%. Nevertheless, this agent appears to entail fewer side effects than less subtype-selective compounds. For example, unlike less selective α-blockers, tamsulosin has not been associated with significant decreases in blood pressure. Also, such adverse reactions as dry mouth and dizziness occurred significantly less often in patients receiving tamsulosin than in those receiving terazosin.

Finasteride is generally associated with fewer side effects than are α-blockers. In one study of 2112 men, side effects led to withdrawal in 2% of finasteride-treated patients.³⁶ In another report, the incidence of adverse experiences with finasteride was similar to that with placebo. Most frequently reported side effects of finasteride treatment involve sexual function. Finasteride-related adverse sexual experiences have been reported in approximately 10% of patients treated for 5 years.

Patient Selection. Drug therapy has customarily been reserved for BPH patients with mild or moderate symptoms. However, based on stratification of doxazosin treatment results across pretreatment symptom severity categories, it has recently been argued that a trial of drug therapy may be appropriate in patients with severe symptoms.²⁹ Patients in this category achieved substantial improvement in both mean peak flow and symptom score. Nevertheless, mean post-treatment peak flow rate (11.3 mL/s) remained below 12 mL/s, and mean symptom score (11.9), in the moderate category. Thus, the final results of drug therapy in patients with initially severe symptoms may prove unsatisfactory in many cases.

Based on a meta-analysis of 6 randomized clinical trials involving 2601 men, treatment with 5 mg of finasteride produced significantly greater improvements than placebo only in patients with prostate volumes exceeding 40 cm³.³⁷ This meta-analysis prompted the suggestion that men with small prostate glands may not be suitable candidates for finasteride therapy. Measurements by transrectal ultrasonography of transition zone volume could be of potential clinical utility in selecting patients for finasteride therapy. When the pretreatment ratio of transition zone to total prostate volume exceeded 0.51, patients were more likely (2.5-fold) to respond to finasteride.

Microwave Treatment or Medical Management?

It has been difficult, until recently, to assess the relative merits of microwave treatment and medical management because of the lack of studies directly comparing these 2 approaches to therapy for patients with BPH. However, a recent randomized, prospective comparison of targeted microwave treatment and α-blockade with terazosin has revealed significant differences between these modalities, as shown in Figure 4.²⁶ At 2 weeks, α-blocker treatment promoted significantly greater improvement in symptoms, Q_max, and QOL score. In contrast, by 12 weeks and thereafter, greater improvements in all 3 outcomes parameters were observed in patients receiving microwave therapy. At 6 months, 78%, 65%, and 84% of the microwave group experienced a 50% or greater improvement in symptoms, Q_max, and QOL score, respectively, compared with 33%, 10%, and 40%, respectively, of the terazosin patients. Based on a multivariate logistic regression model that took account of differences in pretreatment symptoms, targeted microwave treatment was associated with a significantly higher probability than terazosin of achieving at least a 35% improvement in symptoms, with an odds ratio of 31. These observations indicated that microwave treatment provides superior longer-term outcomes for patients with BPH and is appropriate to consider in patients for whom the major priority is greater long-term improvement than is achievable with medical management. The observed advantages of α-blockade in the acute posttreatment period suggested that this modality be considered in patients requiring the most rapid possible relief.

Figure 4.

Mean (a) International Prostate Symptom Score (IPSS), (b) peak urinary flow rate (Q_max), and (c) quality of life (QOL) score with 95% confidence interval in microwave-treated patients (light circles) and in recipients of the α-blocker terazosin (dark circles). Numbers of observations are indicated for each data point. P values are for between-group differences at the indicated time points. (Adapted from Djavan B et al,²⁶ with permission.)

Combination Treatment. The earlier onset of action with α-blockers and the greater long-term efficacy of microwave treatment suggest the possibility of employing these 2 modalities in combination, either sequentially or concurrently. In a recent randomized, prospective study of 41 BPH patients undergoing targeted microwave treatment, neoadjuvant and adjuvant tamsulosin administration resulted in mean IPSS values that were significantly lower at 2 weeks and 6 weeks by 15% and 24%, respectively, than in the microwave-only group (Figure 5).³⁸ Thus, neoadjuvant and adjuvant α-blockade in conjunction with microwave treatment affords the opportunity to achieve both early relief and more substantial long-term improvement. However, a recent study indicates that the early results of microwave treatment can be improved to an even greater extent with placement of an intraurethral prostatic bridge catheter than with neoadjuvant and adjuvant tamsulosin administration.³⁹

Figure 5.

Mean (a) International Prostate Symptom Score (IPSS), (b) peak urinary flow rate (Q_max), and (c) quality of life (QOL) score at baseline and thereafter in recipients of microwave treatment plus the α-blocker tamsulosin (light circles) and of microwave treatment alone (dark circles). Graphic conventions as in Figure 4. (Adapted from Djavan B et al,³⁸ with permission.)

Conclusions

Microwave treatment confers lasting clinical benefits in a single 1-hour treatment session under local anesthesia. The magnitude of improvement in symptoms and voiding function is greater than that with drug therapy, and associated morbidity is comparatively low. Though not infrequent, any subsequent transient urinary retention necessitating catheterization is comparatively brief and manageable. The results of microwave treatment in the acute postprocedure period can be significantly improved either by neoadjuvant and adjuvant α-blockade or by placement of an intraurethral prostatic bridge catheter. Microwave treatment also offers greater versatility than drug therapy, allowing, for instance, patients with severe baseline symptoms and relatively small prostate glands to be treated successfully.

Medical management effectively improves symptoms and voiding function, though to a more modest extent than does microwave treatment. In the case of α-blockers, onset of action is rapid, and treatment effects are readily reversible, if necessary. However, side effects limit the utility of α-blockers. Finasteride treatment leads to comparatively small symptom and flow rate improvements and requires months to achieve maximal patient response. Nevertheless, this 5α-reductase inhibitor offers a favorable safety and tolerability profile. Both α-blockade and 5α-reductase inhibition must be continued indefinitely to maintain treatmentinduced improvements in patients with BPH.

Main Points.

• Transurethral microwave thermotherapy (TUMT) provides lasting symptom relief, increased peak urinary flow rate (Q_max), and enhanced quality of life for patients with lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH).

• For patients with LUTS from BPH, pharmacologic blockade of α-adrenergic receptors can provide symptomatic relief; inhibition of 5α-reductase enzyme reverses androgen-mediated prostatic hyperplasia.

• Some microwave treatment systems have the capacity for more accurate microwave energy targeting than others.

• α-Blockers such as terazosin, doxazosin, and tamsulosin are similar in their effectiveness for relieving symptoms and increasing Q_max, but they differ in their side effects.

• Neoadjuvant and adjuvant α-blockade in conjunction with microwave treatment affords the opportunity to achieve both early relief and more substantial longterm improvement.

• An intraurethral prostatic bridge catheter can help accomplish earlier symptom improvement and voiding function following TUMT.