Transurethral Needle Ablation of the Prostate

Overview of treatment by TUNA for prostate symptoms

Transurethral needle ablation of the prostate is a minimally invasive procedure that alleviates urinary symptoms due to the prostate. It is an outpatient or day surgery procedure that significantly improves urinary symptoms due to the prostate and preserves normal ejaculation. It has advantages over traditional treatments such as TURP, which is more invasive and associated with more problems. However, there is less long term data to support its use and it may not work quite as well as TURP or laser prostatectomy.

Why have TUNA for prostate symptoms?

If there are symptoms attributable to prostate enlargement, then TUNA may be effective. In general, symptoms have to be bothersome otherwise it is difficult to improve the situation. The extent of the symptoms can be evaluated by symptoms scores. TUNA is more effective than medications and avoids the need to take these everyday and their associated side-effects, which can include smaller volumes of semen on ejaculation. Compared to other surgical options, it avoids the more serious side-effects such as blood loss, which may require a blood transfusion, or a dry orgasm (reduced or no semen on orgasm) that can occur with TURP or laser prostatectomy. No hospital admission is usually required and this can reduce the risk of infection by hospital bacteria.

What are the advantages of TUNA?

Advantages include:

limited anaesthesia requirement (local rather than general)
ability to perform the procedure in an outpatient setting rather than being admitted onto a hospital ward or in a room
avoidance of serious complications sometimes associated with other procedures such as bleeding, infection and incontinence
preservation of normal ejaculation and erections

How well does TUNA work?

Men experience a stronger flow of urine, shorter time in the toilet when passing urine and longer intervals between visits to the toilet. If the bladder did not empty before surgery, then getting up a night may also improve. After a year, the urgent desire to pass urine that some men suffer also gets better.

Data from several studies have shown that the overall average improvement in urinary symptoms was 58% at 1 year, 60% at 2 years, and 66% at 3 years.

Men who had severe symptoms (IPSS 21 out of 35) found that their symptoms reduced significantly (IPSS 9 out of 35) after 2 years. In addition, the strength of urinary flow doubled and the bladder emptied more completely. The improvement was durable. At 5 years, men with severe symptoms (IPSS 24 out of 35) were significantly better (IPSS 11 out of 35).

Prostate size does not change after TUNA, nevertheless symptoms, bladder emptying and urinary flow all improve.

In men having TUNA because of a complete inability to pass urine ('acute urinary retention'), about 4 in 5 men can pass urine successfully afterwards.

What are the risks or disadvantages of TUNA?

The death rate is virtually 0 and the morbidity negligible.

As the prostate initially swells after the procedure, about 2 or 3 in 10 men find they cannot pass urine and need to use a tube to drain the bladder (catheter) for a short period of time (12 hours to 2 days). A deterioration in urinary symptoms affect 4 in 10. It is is not unusual to have visit the toilet more frequently, urgently, and sometimes with discomfort or pain. Usually these resolve after 7 days, but may take up to 28 day.

Blood may be present in the urine for the first day or so and this is common for most procedures performed on the prostate. This is usually self-limiting and an increase in fluid consumption helps clear the blood.

An infection may appear but is rare when antibiotics are taken for a 3 to 5 days after the procedure.

Like any cystoscopic (telescopic) procedure, a urethral stricture can occur. The rate is about 2%, which is less than after TURP. A stricture is a narrowing in the urethra that may need treatment by stretching.

Problems with erections occur in about 2% and impotence in 3%. Conversely, about 15% of men say their erections improve. There is little or no incidence of a reduction in ejaculatory volume ('retrograde ejaculation').

As no tissue is removed, none can be examined to determine if cancer is present. However, if that is a potential concern, it may be appropriate to consider prostate biopsies. The chance of an cancer is based on the PSA, what the prostate feels like, the age of the patient and other factors that contribute to predict the probability.

What are the alternatives to TUNA?

The alternatives are drugs:

Alpha blocker medication such as tamsulosin or alfuzosin improve symptoms by about 35% or about 5 IPSS points in more than half of patients. The volume of semen is reduced ('retrograde ejaculation) and some people may feel tired or light headed from time to time.
5 alpha reductase inhibitor medication such as finasteride or dutasteride shrink the prostate by about 20% and improve symptoms over 6 months by about 5 IPSS points. Semen is altered and it is not safe to conceive whilst taking the drugs. Sometimes, there can be some breast enlargement.
Combination Alpha blockers and 5 alpha reductase inhibitor medication: these are effective and reduce symptoms by about 7 IPSS points. Over the long term, there is reduced chance of needing surgery for the complete inability to pass urine or bad symptoms.

Other minimally invasive options are:

transurethral microwave therapy: this is also minimally invasive and enjoys many of the advantages of TUNA, but retrograde ejaculation still occurs.

Alternative surgical options are more invasive, but almost all result in retrograde ejaculation. The advantage is that the effects are more likely to prolonged and the need for repeat treatment is much less. These include:

TURP (transurethral prostatectomy) is the gold standard of treatments for urinary tract symptoms due to the prostate. The symptom score is reduced by as much if not more than TUNA. TURP has many more potential side effects during and after the operation.
Bladder neck incision/transurethral incision of the prostate is only suitable for small prostate. There are fewer side-effects compared to TURP but more than TUNA
Laser prostatectomy: this is a minimally invasive procedure with very little bleeding. It removes move of the obstruction associated with prostate enlargement, has very little need for a blood transfusion but can still result in reduced semen volume.

Are any special tests required before TUNA?

To make sure that a man has the appropriate prostate that can be treated well by TUNA, the following tests or investigations are usually necessary in addition to those necessary to evaluate symptoms:

ultrasound scan of the prostate: an ultrasound probe is through the anus to scan the prostate. It may be uncomfortable, but no needles are used and it is not painful. This gives the size of the prostate which determines how TUNA is performed.
telescope examination of the bladder (flexible cystoscopy): this is to evaluate the shape of the prostate and rule out other potential reasons that may cause urinary symptoms or prevent treatment by TUNA.

In some men, biopsies from the prostate may need to be taken to exclude prostate cancer. If prostate cancer is found, then alternative treatments may be necessary.

How do you prepare before treatment by TUNA?

No specific preparation is required. If the procedure is to be performed under general anaesthetic, you should not eat 5 hours before and not drink 4 hours before. Someone should be available to take you home afterwards. Some time off work should be allowed.

If you have a urine infection, antibiotics will be needed before treatments

How is TUNA performed?

After changing into a hospital gown, you are taken to where the procedure is performed. Another ultrasound of the prostate is performed and local anaesthetic is placed around the prostate to make it go numb. A pad is placed on the skin. Whilst lying on your back and with your legs elevated, the doctor will insert jelly with local anaesthetic down the urethra ('water pipe') before passing a telescope to see the prostate. Needles are introduced into the prostate to allow radiofrequency energy to deliver heat and treat the prostate.

The procedure takes between 30 minutes and 1 hour.

A catheter tube is placed to drain urine from the bladder through the urethra. This is required for about 48 hours.

What is life like after TUNA?

The catheter is removed about 2 days after the procedure. Nine out of 10 men will pass urine after the catheter is removed, but about 1 in 10 men will need the catheter passed again for a short period. A catheter is needed because of the swelling caused by procedure, but this resolves quickly.

Antibiotics whilst the catheter is in place and for 3 to 5 days after the catheter has been removed.

Urinary symptoms may be worse for the up to to 6 weeks after TUNA. Between 2 and 6 weeks, symptoms should begin improving and improvement continues for up to 3 months.

You can usually return to work with 2 or 3 days after the treatment.

Is TUNA painful?

Discomfort may be felt at the time, but considerable local anaesthetic is used to make the procedure as comfortable as possible. If regional or general anaesthesia is used, there is usually no discomfort.

Is TUNA performed once only or does it need to be repeated?

After 5 years, 75% still find their symptoms are better than before treatment. In those men who have problems, TUNA can be repeated.

What happens if TUNA doesn't work?

If TUNA has not worked with 6 months of treatment, it may be better to consider one of the other surgical options (TURP/laser prostatectomy), although these have a much higher incidence of retrograde ejaculation (much smaller volume or no semen on ejaculation), although the sensation of orgasm is preserved. In general about 2 in 10 men may eventually need a TURP after TUNA at some point.

Who does the treatment and does experience matter?

Doctors need to go through a specific training course before carrying out this procedure. Also skills in transrectal ultrasound are necessary in order to select appropriate patients who might do well with this TUNA.

Will my erections be affected?

In general, erections are unchanged. Rarely (less than 2%) say their erections are affected.

Will I be able to ejaculate?

The majority of men are still able to ejaculate when they have an orgasm. Other treatments such as TURP and laser prostatectomy may result in retrograde ejaculation. This means that when orgasm occurs, semen passes into the bladder rather than out of the erect penis. Thus, either no semen is ejaculated or a much smaller amount. When passing urine later after orgasm, semen is also passed. TUNA does not have this side-effect in the vast majority of men.

Who is suitable for treatment by TUNA?

Men with urinary symptoms attributable to the prostate are suitable for TUNA. The prostate should be less than 60 gm in size and there should not be bladder neck obstruction (i.e. a high bladder neck). In the past, it was thought that median lobe enlargement (a particular shape of prostate enlargement) could not be treated by TUNA, but this can also be treated. For men who want normal ejaculation, TUNA is ideal.

Who is unsuitable for treatment by TUNA?

Men who have urinary symptoms not attributable to the prostate (e.g. isolated detrusor overactivity): reduction in caffeine, fluid consumption and drugs are the first line of therapy
Certain prostate configurations including a high bladder neck (the junction between the bladder and the prostate): better treated by a bladder neck incision (i.e. a simple incision of the bladder neck)
Excessively large prostates (more than 60 gm): these are better treated by TURP or laser prostatectomy
men with prostate cancer: treatment for that condition alone.
Severe obstruction by the prostate that might be better treated by TURP or laser prostatectomy

Certain neurological conditions (e.g. myasthenia gravis, multiple sclerosis, or Parkinson disease) give rise to urinary symptoms in their own right. In such cases, extra special care should be taken to ensure that the prostate is in fact the primary cause for the symptoms. Video-urodynamic studies are necessary before surgery otherwise incontinence may results. If there is uncertainty about the benefit of a TURP, a prostatic stent can be inserted as this can be removed simply. Similarly, severe pelvic fractures can also give rise to incontinence after surgery.