Thick vs thin loop transurethral resection of the prostate: a double-blind prospective trial of early morbidity

Benignes Prostatasyndrom (BPS)

Today, the surgical treatment of the benign prostatic syndrome (BPS) often follows a course of drug treatment. Besides conventional transurethral resection of the prostate (TURP), which has represented the standard therapeutic option for decades, and its in part significant modifications ("vaporizing resection"; bipolar resection), much of the interest has shifted to alternative instrumental procedures like transurethral microwave therapy (TUMT), transurethral needle ablation of the prostate (TUNA) or several laser techniques. By reviewing the current literature, preferably from randomized controlled trials, these different procedures are critically assessed. Moreover, the present role of open prostatectomy is discussed.

Transurethral Electrovapor Resection versus Standard Transurethral Resection Treatment for a Large Prostate: A 2-Year Follow-Up Study Conducted in Taiwan

INTRODUCTION

Those patients featuring a large prostate and undergoing transurethral resection typically face a longer duration of surgery, they have a higher degree of hemorrhage and a higher irrigant volume required for the procedure, and they tend to reflect a higher incidence of morbidity than is the case for a small prostate. We report on the relative safety and efficacy of transurethral electrovapor resection of the prostate (TUVRP) as compared with standard transurethral resection of the prostate (TURP) for Taiwanese patients having a prostate size >50 ml.

PATIENTS AND METHODS

Seventy-six symptomatic benign prostatic hyperplasia patients featuring a prostate size >50 ml were randomized and underwent either TUVRP using wedge loop or standard TURP. Perioperative parameters, treatment outcome, and adverse events associated with the surgical procedure are assessed herein.

RESULTS

Mean operation time, changes in hemoglobin levels, resected prostate weight, perioperative irrigant volume needed, and incidences of recatheterizations and readmissions, all differed significantly when the two surgical procedures were compared. The average expense differences for the two procedures were impressive (p < 0.0001). No postoperative intergroup sexual dysfunction differences were noted. Clinical improvements following either TUVRP or TURP were significant and sustained for at least a period of 2 years. Intergroup comparison of International Prostate Symptom Score, quality of life, peak flow rate, and postvoid residual volume revealed no significant differences at 2 years (p = 0.45, 0.48, 0.12, and 0.29, respectively). The need for postoperative medical retreatment and/or reoperation did not differ significantly between the two groups (p = 0.62 and p = 0.56, respectively, at 6 months and p = 0.47 and p = 0.48, respectively, at 2 years).

CONCLUSIONS

The TUVRP procedure offers advantages as regards a number of perioperative parameters when compared with the TURP procedure, and it seems that TUVRP might provide at least an equivalent treatment outcome as is the case for TURP.

Techniques and long-term results of surgical procedures for BPH

OBJECTIVE

To provide an overview on the current status of the long-term outcomes of instrumental treatment options for patients with lower urinary tract symptoms that are suggestive of bladder outlet obstruction.

METHODS

Based on MEDLINE database searches, we performed a systematic review of the literature with a focus on peer-reviewed articles about surgical benign prostatic hyperplasia (BPH) therapy published between 2000 and 2005. Special emphasis was given to randomized controlled trials on long-term outcome with a minimum follow-up of five years.

RESULTS

Data on clinical outcome with a follow-up of more than 10 years are available for open prostatectomy (OP), transurethral resection of the prostate (TURP), and transurethral microwave therapy. Studies with a follow-up of at least five years are obtainable for transurethral incision of the prostate, transurethral vaporisation of the prostate, transurethral needle ablation of the prostate, Holmium:YAG laser enucleation of the prostate, potassium-titanyl-phosphate laser vaporization of the prostate, and interstitial laser coagulation of the prostate. Among these long-term reports, OP and TURP provide the most durable results.

CONCLUSIONS

The most substantial long-term data on surgical procedures for BPH are available for conventional therapy, namely TURP. Concerning the techniques that have emerged within the last decade, there is clear evidence that the outcomes are more sustainable for truly ablative and thus deobstructing procedures.

Transurethrale Resektion bei benigner Prostatahyperplasie

Transurethral resection of the prostate still represents the "gold standard" in surgical treatment of symptomatic benign prostatic enlargement (BPE). New demands were made on transurethral electrosurgery with the appearance of alternative, minimal invasive procedures. Bleeding complications had to be reduced. Different attempts were made to improve the conventional TURP. Band loops and roller bars were developed in order to gain a more effective coagulation during the cutting process by a larger tissue contact. Major advances could be achieved by modifications of the high-frequency generator. Improved procedures like the "Coagulating-Intermittent-Cutting" (CIC), the "Instant-Response-", as well as the "Dry-Cut-Technology" combine cutting and coagulating effects to realize lowered bleeding and an efficient resection process. The introduction of bipolar currency flow opens the possibility of conventional TUR-P with saline solutions and thus to the theoretical avoidance of the TUR-syndrome. By the neoadjuvant use of 5alpha-reductase-inhibitors before planned TUR-P, bleeding- and irrigation fluid absorption should be reduced by lowering perfusion and the size of the prostate. Regarding these innovative approaches which improve the surgical standard and minimize the risk of perioperative complications, transurethral electrosurgery remains the method of choice in instrumental therapy of symptomatic BPE. In the future efficacy and costs will be comparable to those of the transurethral laser-resection or laser-vaporisation.

Prospective randomized controlled trial comparing plasmakinetic vaporesection and conventional transurethral resection of the prostate

OBJECTIVE

Plasmakinetic vaporesection of the prostate (PKVP) using normal saline irrigation has the theoretical advantage of avoiding transurethral resection syndrome and minimizing blood loss. It may also shorten the operative time since tissue is resected instead of just vaporized. The aim of this study was to evaluate the efficiency, safety and advantages of PKVP compared with standard transurethral resection of the prostate (TURP) at a regional acute hospital.

METHODS

A total of 60 consecutive men admitted from a waiting list for surgery for benign prostatic hyperplasia (BPH) were prospectively randomized to either PKVP or TURP. Peri- and postoperative outcome data at 3 months were obtained.

RESULTS

The PKVP loop achieved a fast and sharp cutting action similar to that with the traditional TURP loop. Data analysis was based on 51 patients. There were no significant differences between the methods in resection time, postoperative catheterization time and hospital stay. The mean reductions in serum sodium 2 hours after PKVP and on postoperative day 1 were 0.52 mmol/L and 3.35 mmol/L, respectively, while mean reductions in haemoglobin were 0.36 g/dL and 0.24 g/dL, respectively. There was no significant difference in haemoglobin reductions between PKVP and TURP (p = 0.326 at 2 hours; p = 0.192 on day 1) and serum sodium (p = 0.757 at 2 hours; p = 0.888 on day 1). Both groups achieved comparable improvement in International Prostate Symptom Score (p = 0.862), quality-of-life score (p = 0.169) and peak flow rate (p = 0.96) at 3-month follow-up.

CONCLUSION

PKVP achieved comparable results to traditional TURP and was an effective and safe procedure. However, it did not demonstrate obvious advantages over TURP in this acute regional hospital regular TURP list setting.

Thick Loop Prostatectomy in the Endoscopic Treatment of Benign Prostatic Hyperplasia: Results of a Prospective Randomised Study

OBJECTIVE

The thick loop is a new device employed for transurethral resection of the prostate (TURP) using the standard resectoscope. The loop is broader and thicker than the standard one, resulting in better hemostasis because of its ability to cut, coagulate and vaporize tissue simultaneously. We evaluated the safety and efficacy of the thick loop device compared with the standard loop.

PATIENTS AND METHODS

103 patients with symptomatic benign prostatic hyperplasia were randomized to undergo either thick loop (51 patients) or standard loop TURP (52 patients). Patients were considered for surgery with the American Urological Association (AUA) symptom score greater than 7 and a maximum urinary flow rate <15 ml/s. Serum hemoglobin, hematocrit, electrolytes, operative time, prostate resected weight, catheterization time and complications were recorded. Twelve months later, the AUA score, maximum urinary flow rate (Q(max)) and postvoiding residual urine volume were evaluated.

RESULTS

There were no significant differences between thick and standard loop TURP regarding the operative and catheterization time, prostate resection weight and postoperative levels of hemoglobin, hematocrit and electrolytes. Twelve months after TURP, the AUA score was significantly lower and Q(max) greater in the thick loop compared to the standard loop groups.

CONCLUSIONS

Thick loop TURP is as safe as standard loop TURP with respect to blood loss, operative time and complications. Operating in a virtually bloodless field could allow a more radical TURP and provide an explanation for the better functional results (Q(max) and AUA score) obtained by the thick loop resection.

Ex-vivo comparison of the haemostatic properties of standard transurethral resection and transurethral vaporization resection of the prostate

OBJECTIVE

To compare the haemostatic properties of standard transurethral resection of the prostate (TURP) and transurethral vaporization resection of the prostate (TUVRP), as perioperative bleeding is still regarded as the major complication of prostate resection.

MATERIALS AND METHODS

Isolated blood-perfused porcine kidneys were used to determine the haemostatic efficacy of TURP and TUVRP (using two different electrodes). Bleeding was quantified precisely in relation to tissue ablation for the two techniques, and specimens were evaluated histologically.

RESULTS

Both TUVRP groups had significantly less bleeding (P = 0.005) than the TURP group for a standardized ablation volume of perfused kidney tissue (18.9, 19.5 and 24.1 mL/min, respectively). The different TUVRP electrodes had no significant haemostatic differences. The histology showed significantly (P = 0.03) larger coagulation zones for the TUVRP groups than for standard TURP.

CONCLUSIONS

TUVRP ex-vivo was associated with significantly better haemostasis than TURP. The haemostatic properties of different active electrodes for TUVRP seem to be equivalent.