Freehand Ultrasound-Guided Transperineal Microwave Ablation for Benign Prostatic Hyperplasia: A Novel Application

The development of minimally invasive surgical therapies (MISTs) for benign prostatic hyperplasia (BPH) focuses on achieving effective lower urinary tract symptoms (LUTS) relief while preserving sexual function. While early investigations explored transperineal microwave application, we present the inaugural experience with a contemporary freehand ultrasound-guided transperineal microwave ablation (TPMA) technique as a novel MIST application. Two patients with symptomatic BPH underwent TPMA. Case 1 was a 54-year-old male (prostate volume 53 cc, International Prostate Symptom Score (IPSS) 27) seeking ejaculatory preservation. Case 2 was an 80-year-old male (prostate volume 69 cc) with a 15-month history of indwelling urinary catheter dependency. Procedures were performed under light intravenous sedation using a 16-gauge microwave antenna. Ablations were delivered at 20-30 W for 30-60 seconds per application using a freehand "moving shot" technique, under biplanar transperineal ultrasound guidance, maintaining an 8mm safety margin from the urethra and bladder neck, with an apical-sparing strategy. Procedures were successfully performed, with same-day discharge and catheter removal on postoperative day five. At six weeks, both patients showed marked improvement: Case 1: IPSS 27 to 7, Qmax 16.8 to 26 mL/s, with antegrade ejaculation preserved. Case 2: achieved catheter-free voiding (Qmax 27 mL/s, IPSS 8). Both were off alpha-blockers. No Clavien-Dindo ≥II complications occurred. Freehand ultrasound-guided TPMA appears to be a safe and feasible novel outpatient procedure for the treatment of BPH. This technique demonstrates promising short-term efficacy in relieving obstruction and may offer the potential for ejaculatory preservation. TPMA may represent a valuable addition to the MISTs arsenal, warranting further investigation in larger prospective studies.